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What are Proper Fees for the Average Dentist?*
W H A T ARE PROPER FEES FOR THE AVERAGE DENTIST?* By H EN R Y A. HO NO RO FF, D.D.S., Chicago, III.
H E term “ average den tist” is too often used rath e r vaguely and loose ly, and since I shall employ it from tim e to tim e as describing a certain defi nite individual, or a group of individuals, an effort w ill be m ade to w ard a clear understanding as to the m eaning of this term . Because of the complex hum an factors th a t m ust necessarily en ter into the ethical practice of dentistry, it w ould be impossible to point o u t certain groups of dentists, and classify them as superior, average or inferior, in accordance w ith the discharge of their professional obliga tions to their patients and w ith their ability to carry out the necessary tech nical procedures. I t is all too obvious, and the instances are too num erous to require any proof fu rth e r th an the con tention th a t m any of the so-called w iz ards and superm en of the profession are very often not up to par, either in their ability or the desire to do the proper thing by th eir patients. O n the oth er hand, it has been am ply dem onstrated th a t some of the finest dental operations and the m ost laudable self-sacrificing perform ances for the benefit of dental patients have come from dentists of a very hum ble and unassum ing type, whose names nearly always rem ain in obscurity.
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*Read before the Section on D ental Eco nomics a t the M id w in ter C linic of the C hi cago D ental Society, Feb. 3, 1931. Jour. A. D. A-, April, 1931
T h e average dentist, then, should be looked on and accepted not as a dental p ractitioner of average ability, or of ability below the grade of those w ho are considered or wish to be considered as of high standing. R ath er, he should be judged by the caliber and social standing of his patients. H e is an average dentist w ho conscientiously, and to the best of his ability, m inisters to the d ental needs of the average citizen, of average means and of average requirem ents. T h e “av er age d en tist” can be considered only as here defined in the attem p t to arrive at a certain figure w hich may be looked on as his proper fee. A ll observations and con clusions in connection w ith the gaging of this fee can be based only upon the social standing and m aterial needs of the aver age dentist. I t is only these tw o condi tions, and not his professional standing, th a t make it necessary for the dentist to accept cash paym ent for his service. As a m em ber of m odern society, the average dentist cannot consider himself an exception to the rest of the com m unity in w hich he lives and carries on his w ork. H e is not im m une to the needs and obli gations w hich affect the social stru ctu re su rrou n d in g him, and he is subject to all economic rules and regulations which are imposed on all average citizens. H e is required to pay ren t and taxes. H e m ust pay fo r food, clothing, light, power, labor and m aterials in the same m anner as
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H onoro ff— Proper Fees for Average Dentist the rest of the com m unity; and he th e re fore m ust purpose to receive as rem u n era tion for his efforts, along w ith the satis faction th a t comes from giving good professional service, a m aterial rew ard w hich w ill enable him to m eet his obliga tions honorably. T h e pleasure th a t comes to the dentist from the realization th a t he has served w ell and from the g ratitu d e of his pa tients w ho are m ade happier through his service is not only the im pelling force w hich inspires him to do his w ork w ell but also the spiritual rew ard for the many sacrifices w hich he m ust make in the conscientious perform ance of his profes sional duties. T h is feeling of pleasure, although essentially a rew ard, cannot be governed by economic form ulas, cannot be evaluated in a pecuniary sense, and no attem pt shall be made here to set a price on it. O n e m ust be imbued w ith certain ideals and aspirations before one can u n dertake the proper practice of dentistry. Indeed, the situation w ould be ideal if the dentist could give himself entirely to serving hum anity in his especial ca pacity w ith o u t ever having to th in k of m aterial compensation. T h is ideal condition has not yet a r rived. T h e average dentist still finds him self in a w orld w hich is m aterialistic, sophisticated and hard-boiled, and in o r der to facilitate the proper functioning of his professional body and m ind, he m ust arm himself from head to foot w ith protective elem ents. H is resistance can be much strengthened by the injection of large doses of economic principles into his system. Society is expecting the dentist to fu l fil his mission in life. I t expects him to relieve pain, prevent disease and cure the afflictions w hich verily endanger lives, but it also dem ands, in no uncertain
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term s, th a t he pay his bills. If he does not satisfy dem ands for paym ent, this hum an benefactor is uncerem oniously dealt w ith by the same society for w hom he w orks so hard, and whose health and w elfare are his constant concern. T h ese objects of his professional devotion w ill shut off his w ate r and gas supply. T h ey w ill disconnect his telephone and shut off his light. T h ey w ill even p ut him o ut in the street, and take his home away, should he dare not to pay his bills. W ith all these dangers th reatening him, the dentist cannot loosen himself from the iron grip of m aterial dem ands and circum stances. H e is forced to aban don his ideas of p ure m issionary service, and he m ust mix business w ith his pro fession. T h e role of business m an is forced on him by society, and contrary to professional traditions, he m ust assume the position of salesm an, and consider his patients as custom ers in connection w ith the practice of his profession. In the same light, the dentist m ust consider himself an employe, and his patients have to be viewed as his employers. So, w h eth er he likes it or not, the average dentist is doctor, salesman and laborer all in one, and in his daily life he m ust conduct him self in a m anner th a t w ill satisfy all w ho have placed him in these three categories of hum an endeavor. H e m ust ad ju st him self to conditions as they are. H e m ust be able to solve his w orldly dilem m as in a practical way. G ra n tin g th a t his service is satisfac tory, his patients, having paid him w h at he him self has designated as a fee for th a t service, are justified in thinking th a t the dentist has been fu lly rew arded, and they have a rig h t to expect him to be able to m eet his financial obligations to them . W h y , then, is it th a t m any dentists are unable to pay th eir bills? W h y is it, then, th a t, according to the best in fo r
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m ation obtainable, th e n et yearly income of the average dentist in the U n ited States is less th a n $ 4,000? W h y is it th a t 50 per cent of the dental profession are delinquent in paying their d en tal sup ply bills? T h e fa u lt certainly is not w ith the public. T h e y are paying the dentist w h at he is asking them to pay, and th eir obli gations to him are apparently discharged honorably. F rom this, it follow s th a t the fee, o r the financial aw ard, set by the dentist himself fo r his w ork has been in adequate and insufficient to cover his necessary expenditures. T h e dentist, then, m ust look upon him self as the cause of his financial troubles, and he m ust m ake a thorough search w ithin the realm s of his ow n being, and th e confines of his ow n practice to find o u t w h at he him self does th a t is placing him in an economic predicam ent. H e m ust, first of all, fam iliarize him self w ith the various factors and principles th a t govern and determ ine com pensation for professional service. H e, also, m ust con d u ct his office and practice is strict accord w ith those principles. A s has been pointed out, the average d entist is n o t only a w age earner, but also the head of a business institution, and as such he is entitled, as economists rec ognize, to a re tu rn purely from th e sale of his product. T h e allotm ent of his fee, then, should be governed not alone by his necessities, com forts and luxuries, w hich are the m ain forces in the determ ination of a lab o rer’s w age. In the distribution of its w ealth, society m ust allow a share for the average dentist w hich is large enough to provide fo r all the three factors m en tioned, and also to cover all expenses in cidental to the ru n n in g of a d ental office, including interest on capital invested, de preciation and some net profit. T h is net
profit m ust be am ple enough, w hen set aside for th a t purpose, to provide a fair income for th e d en tist in his declining years, w hen he is no longer able to w o rk . T h is portion of the public w ealth so allotted to the dentist may be term ed as his fee. T h is sort of fee, to be considered p ro p er, does n o t necessarily have to be too high, b ut it m ust be sufficient. Such a fee is h ealth fu l for both patien t and den tist. A low fee makes it prohibitive for the den tist to do good w o rk and a high fee makes it prohibitive for the average patien t to have good w o rk done. In this respect, fees exert the same influence on dental service as do wages on labor, and economic law s th a t are applicable to labor are also applicable to d ental service. Both dentist and lab o rer are hum an, an d they are governed equally by the dictates of hum an n atu re. P ro f. R ich ard T . E ly, of the d ep art m ent of political economy of th e U n i versity of W isconsin, points o ut very vividly the favorable effect th a t good wages have on efficiency in labor. H e says, am ong oth er things : E ven from the standpoint of em ployers as a class, the policy of depressing of thè lab o r e rs’ sta n d a rd of life stands condem ned. M ore and m ore businessm en are com ing to lea rn the “economy of high w ages,” a n d th a t “cheap lab o r is d e a r labor.” A m erican labor is in m any industries the cheapest lab o r in the w orld, because it is the best paid. H igh w ages m ake possible a high sta n d a rd of life. T h e high sta n d a rd of life m akes the lab o re r intelligent, hopeful and full of c h a r acter, as well as m ore efficient physically. T h e increased efficiency m akes possible the h ig h er w ages. T h u s, by action and reaction the sta n d a rd of life is both a cause and result of w ages received.
I t is plain, then, th a t in order for the dentist to give him self w holeheartedly to his w ork, he m ust be paid fo r it in such m easure th a t he w ill n ot be kept in constant w an t. T h e dentist w ho earns a
HonorofJ— Proper Fees for Average D entist mere starv atio n income by the practice of his profession cannot be much enthused over dentistry, and w here th e re is no en thusiasm , there can be no good w ork. L ack of enthusiasm leads to a g rad u al dislike for th e profession, w hich is fol low ed by resentm ent on the p a rt of the dentist to w ard good w ork. T h e inevita ble result is b itter disappointm ent to the dentist and to his friends. As has been shown, his fees have a tre m endous influence on the life and be havior of the dentist, and therefore their determ ination cannot be taken too lightly by him . Still, a study of dental fees as they are today shows definitely th a t thou sands of dentists are n o t giving this m at te r any th o u g h t a t all, and resort mostly to guessw ork and tru s t to luck in setting a fee fo r their w ork. I n looking thro u g h the m any lists of prices for dental w o rk th a t have been gathered by investigators for various d en tal organizations and publications in the past tw o or three years, one glimpses a tragic picture. T hese figures te ll a sad story of how thousands of intelligent, w ell-intentioned and industrious people engaged in th e practice of dentistry are daily com m itting economic suicide. T h e y tell of inverse proportions betw een serv ice and fees, they show vividly th e incon sistencies and lack of application of sim ple logic on the p a rt of a g reat m ajority of dentists to the m a tte r of estim ating costs of dental service. T h ese figures leave nothing to the im agination as to the m any sacrifices and self-denials th a t these grossly underpaid dentists have to contend w ith as a result of th e ir own m ism anagem ent. T h e re is no good reason th a t there should be a state of constant economic depression in the ranks of the dental pro fession. M o st patients pay th eir bills as estim ated and required by the dentist.
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T h e fact th a t the d en tist underestim ates his ow n services an d presents an insuffi cient bill is en tirely u nknow n to them . As a m a tte r of fact, m any patients w ould consider it a personal insult to learn th a t their d en tist had been giving them charity. I t is plainly th e business of the dentist to be able to present the rig h t kind of a bill fo r his services. B u t so far, the dentist has been slow in acquiring know l edge in this respect. Instead, he has ac quired a lo t of bad hab its th a t a re u n d er m ining his financial stru ctu re. Q u ite unnecessarily, and m uch too often, m any dentists play the role of “ big b ro th er” and “good fellow ” in the w ro n g place, and confer uncalled for philanthropies. E ven the best inform ed dentists can recall m ore th an one instance in th eir ow n practices in w hich the show ering of professional ch arity on patients has been accepted by the p atien ts w ith w o n d er m ent as to the soundness of the d o cto r’s m ind. C hief am ong the bad habits of the den tist leading to his financial plight is his indulgence in “ th ro w in g in ” things w ith his w ork as a bonus. O ne w onders if any dentist can w alk into a m erchandise store, purchase a h at and have a p air of shoes “ th ro w n in ” w ith the bargain. T h e very th o u g h t of it w ould be absurd. Y et, m any dentists w ill th in k n o thing a t all of “ th ro w in g in ” a prophylaxis w ith each operation they u n dertake, be th a t operation as sm all as the placing of tw o am algam fillings. M an y w ill undertake the construction of a ru b ber den tu re for a certain fee, and w ill unhesitatingly “ th ro w in ” all the extrac tions th a t m ay be required in connection w ith th a t p articu la r case, w ith o u t any additional charge. Still others w ill “ th ro w in ” all necessary treatm en ts for
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the fee w hich they are accustom ed to charge for the filling or crow n th a t the treated tooth may require. P oor judgm ent, undervaluation of th e ir services and guessw ork are also largely responsible for the financial dow n fall of m any dentists. T h is is perhaps best illu strated by a story told by a past president of the Chicago D en ta l Society of how! a colleague of his m ade a trip to his office in the Chicago loop d istrict from his suburban hom e on Sunday m orning, and afte r spending the w hole m orning in relieving the pain from an incipient alveolar abscess fo r a m illionaire’s little son, nearly knocked the boy’s fath er off his feet w hen he nam ed his fee. “W h a t do I ow e you, D o c to r? ” asked the pa tie n t’s father. “ I appreciate g reatly the fact th a t you p u t yourself out fo r me, and I see you have w orked very h a rd .” “ W e ll,” said the doctor, hesitatingly, afte r some deliberation, “ I guess $ 2 w ill do.” T h is m an sold four hours of his tim e and $ 2 w o rth of railw ay tickets for the sum of $ 2 , besides spoiling the holiday fo r him self and a friend w ith whom he had an appointm ent to play a round of golf th a t m orning. Such poor logic as w as used by this dentist in th e fixing of his fee and sim ilar dem onstrations of undercharging by other dentists are not only detrim ental to the earn in g pow er of the profession, but w h at is m uch w orse than th at, they tend to belittle dental service in the eyes of the laity. H ere and there, a case of dispro portion can be observed, w hen the den tist has p u t too high a value on his serv ices, or has received large sums of money for very little service.’ T hese m en are, of course, the exception, and aside from m entioning th a t there is no room in the ethical practice of dentistry fo r exorbit a n t fees and th a t extortion is n o t a virtue in the professional m an, the discussion
of the m a tte r can be abandoned w ith a feeling of gratification th a t extortionists and quacks are only in a sm all m inority. T h e ir m ethods and fees should have no influence w hatev er on the average dentist. A ll of th e undesirable traits of the average dentist m entioned are to be con sidered as co n trib u to ry causes of dim in ished income and microscopic fees. T h e m ain underlying cause for inade quate d en tal fees is to be found in the lack of know ledge on the p a rt of the aver age dentist of th e actual cost to him of the various types of restorations, opera tions and services for w hich he is called on in his daily practice. A ll available figures, w h eth er ob tained from c u rre n t dental publications, from statistics gathered by bureaus of dental economics o r from piles of data gathered by the dental supply houses, point to one thing, and th a t is th a t the average dentist has a net annual income of less th an $4,000. T h is figure being an average, it follow s, natu rally , th a t there are still thousands of dentists whose net ann u al income is less th an $3,000. If th a t is tru e, th e fees charged by th o u sands of dentists, as shown in m any of the d ental m agazines, are correct. I t m ust be tru e, then, th a t thousands of dentists are m aking a charge of $2 for a one-surface am algam filling, and $3 for tw o surface am algam fillings. T h ese low fees are prim a facie evidence th a t the dentists m aking those charges have abso lutely no idea as to w h at those fillings cost them . T h e fact th a t thousands of dentists are m aking one-surface gold in lays for a fee ranging between $5 and $ 1 0 and tw o-surface gold inlays fo r a fee ranging betw een $7 and $12 is more evidence of the u tte r disregard for the cost of these restorations to the dentist. E ven those dentists who report fairly good incomes show a great need of better
H onoro ff— Proper Fees for Average Dentist und erstanding of the basic economic p rin ciples affecting their fees. P erhaps the m ost autho ritativ e and authentic figures along the lines of fees charged, gross incomes and expenses are to be found in the prelim inary report issued by N o rth w estern U niversity D e n ta l School B ureau of Economics, of a survey for 1929. T h is survey is very valuable. I t reached out to all states and gathered d ata from N o rth w e ste rn alum ni w ho have been in active practice fo r from one to th irty or m ore years. T h e m a jo rity of d ata given in this report w ere obtained from dentists practicing in cities th a t have a population of from 1 0 , 0 0 0 to 500,000 or m ore. T h e figures appearing in the survey w ere subm itted only by oneth ird of the dentists w ho received ques tionnaires. T h ese figures show only large incomes, w hich makes it apparent th a t they w ere given out by successful prac titioners, w ho are w ell paid and whose offices are conducted m ost efficiently. T h e figures could be considered average incomes had the other tw o -thirds of the alum ni sent in their reports. B u t those w ho do not bother answ ering question naires are, generally, m en w ho either have to guess at figures o r whose incomes are so poor th a t they are shy to disclose th eir identity. N atu ra lly , the average annual net in come of $5,480 earned by one-third of N o rth w estern alum ni cannot be consid ered as a typical net ann u al income of the average dentist. T h is figure w ould no doubt be brought dow n to less than $4,000 had the m en receiving the low fees reported their actual incomes to the bureau. T h e rep o rt of the bureau is highly significant because it brings out the follow ing facts: 1. T h e best paid men in the country earn less than $ 6 , 0 0 0 a year net on the average. 2. T h e most efficient men in the country show a m axi
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m um of 1 , 2 0 0 productive hours a year. 3. T h e gross expense of the m ost efficient dental offices is about 35 per cent of the gross income. 4. In o rd er to earn $6,000 a year, p u ttin g in the m axim um num ber of hours hum anly possible to w ork by a dentist, w hich is 1 , 2 0 0 hours, he m ust receive a fee of not less th an $ 8 an hour. 5. T h e uniform stan d ard of life of those dentists as reflected by the uniform ity of their fees can be accepted as the standard of life of all average dentists. C onsidering the social environm ent of the dentist, it is to be observed th a t he cannot live any too extravagantly on $500 a m onth, and no dentist need fear th a t his fees are too excessive if he sets o u t to earn $500 a m onth. A t a m ini m um , the average dentist has only 1 , 0 0 0 gainful hours a year, and the office ex pense of the average dentist is 40 per cent of his gross income. T o arriv e at a fee of $ 6 n et an hour, th e average dentist m ust charge $ 1 0 gross an hour. O n e m ust take into consideration the fact th a t the num ber of years of a den tist’s m axim um production are very few. I t takes some years be fore one a ttain s m axim um production, and having reached the top of his ability to produce, one m ust reckon w ith the physical impossibility to m ain tain top speed indefinitely. T h e num ber of active years th a t the average dentist has for the practice of his profession can be divided into three periods. T h e first are the years given to the building up of his p ractice; the second, th e years d u rin g w hich the zenith of his professional achievem ent has been rea ch ed ; the th ird is m ade up of those years d u rin g w hich his practice m ust assume a dow ngrade course. I t is clear, then, th a t the period of m axim um production m ust give the dentist a revenue w hich should be a m p k to m ake up fo r the insufficient income of
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the years previous to and follow ing those of m axim um productivity. Since he has only a very short tim e in w hich he can receive fu ll financial rew ard for his pro fessional efforts, the dentist cannot af ford to w aste th a t tim e. H e m ust use it sparingly and judiciously as som ething very precious, as the only th in g on w hich depend his own happiness and the hap piness of his fam ily. H e m ust learn the actu al value of his tim e in dollars and cents, and he m ust learn to apply th a t tim e value to the cost of the various pro cedures, operations and restorations for w hich he is called on in his daily practice. T o express this in term s of business: P atients come to the dentist to buy fill ings, crowns, inlays, plates, bridges, etc. T h e dentist, w ho sells those things, m ust know their exact cost. L acking in the know ledge of cost, he cannot sell his com m odity rightly. H e is a p t to charge either too m uch or too little* doing an injustice either to him self o r to his patients. I t so happens th a t m ost dental opera tions and procedures are of a character th a t allow s of a certain definite am ount of tim e to be apportioned to each one of them . T h ey can practically all be meas ured in tim e units, w hich makes it pos sible to affix to them a certain definite financial value. A ll th a t one has to do is to m ake use of th e sim plest form of record keeping and the sim plest rules of arithm etic. H av in g m ade a hundred onesurface am algam fillings, and having kept stric t record of the tim e taken up by these fillings, the dentist can find out for him self the average length of tim e th a t he spent in th e m aking of an am algam fill ing, by dividing the to ta l num ber of hours by the num ber of fillings. T h e same m ethod can be applied to th e gold inlay, to the various types of crow ns, to tre a t m ents, to synthetic porcelain fillings, etc. H av in g determ ined th e average length
of tim e required by each operation, the dentist m ust n ex t m ake it his business to find o u t the cost to him of th a t tim e in actual cash. T h is he can do by dividing the to ta l an n u al office expense by the num ber of hours he actually w orks at the chair and in th e laboratory. F o r example, if he w orks the m axim um of 1 , 2 0 0 hours a year and his gross office expense is $3,600, each w orking h o u r has a cost value of $3. T h is cost per hour, by the way, is applicable to all average dental offices. T h e d en tist w ho only w orks 1 , 0 0 0 hours and has a gross expense of $3,000 is also paying $3 an hour for the privilege of practicing dentistry. A pply ing this tim e value to the simple occlusal am algam filling, one can easily arrive at the cost to him of th a t operation. F rom statistics com piled by me, it can be said w ith a fair degree of exactness th at, on the average, it takes twenty-five m inutes to m ake a simple occlusal am algam fill ing, using proper m ethods of cavity prep aration and including polishing. Since the low est cost to the average dentist of doing business is $3 an hour, tw enty-five m inutes of his tim e costs the average den tist $1.25. A dding the cost of m aterial, w hich is 15 cents, to the tim e value, it is established th a t the simple occlusal am al gam filling costs the dentist $1.40. T h e dentist w ho sells these fillings at $ 2 is getting a fee of 60 cents fo r tw enty-five m inutes, or $1.40 an hour. If he w ere to m ake n o thing b u t simple occlusal am al gam fillings all th e year ro u n d a t th a t rate, he w o u ld have a m axim um annual net income of $1,680, or $35 a week, which, of course, is a very poor w age for a pro fessional m an. A t $3 fo r each simple occlusal am algam filling, the net fee for each ho u r w o u ld be $3.84 and the m axi m um net an n u al income w ould be $4,608. A t $ 4 for each simple occlusal am algam filling, the net fee for each h o u r w ould
Honoroff— Proper Fees for Average D entist be $6.24, w hich is about the rig h t fee for the average dentist. T h e actual cost to the den tist of the gold inlay is established in this m anner. I t takes on the average one and threeq u arte rs hours to produce a gold inlay, using proper cavity preparation, im pres sion taking, casting, polishing and setting. T h is tim e has a cost value to the dentist of $5.25, the m aterial used has a value of $1. In all, the gold inlay has a cost value to the dentist of $6.25, on the average. T h e dentist w ho makes gold inlays a t $5 is giving his labor for nothing, and be sides he is paying his patients $1.25 in cash as a bonus fo r being allow ed to prac tice his a rt in the m ouths of those patients. T h e dentist w ho makes gold inlays for $6.25 is ju s t w orking fo r nothing, b u t is not giving his patients any “ pocket m oney.” T hose men w ho m ake gold in lays at $ 1 0 , and there are m any in this class, are earning a net profit of $3.75 fo r each inlay, or $ 2 an hour, and those w ho get $15 for each gold inlay are m ak ing about $5 an hour net. T o m ake a net profit of $ 6 an h o u r on gold inlays, one has to charge $16.75 for the average in lay. I t is peculiar but tru e th a t the men w ho m anage to get $3 fo r each simple occlusal am algam filling, thus earning close to $4 an hour net, are selling gold inlays a t $ 1 0 or less, prices w hich bring them only $2 an hour or even less. I t is logical to expect th a t a gold inlay restora tion, w hich requires finer taste and bet te r skill, and m ore intense application of the o p erator’s resourcefulness, should com m and a b etter fee than does the sim ple am algam filling; still, the tim e con sum ed by the gold inlay is sold by the m ajority of the profession for a half of the price th a t they are getting for the tim e used up by the am algam filling.
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T h is condition can be attrib u ted only to the fact th a t m ost dentists do not know the value of the inlay. T h e y seem to base their charges only on the cost of m aterial, fo rg ettin g the cost of time. G o ld crow ns take about the same am ount of tim e an d m aterials as inlays, and the fee for gold crow ns should be the same as the fee fo r inlays. T h re e-q u arte r crow ns take tw o hours, and $1.50 w o rth of m aterials, and the fee for them should be figured on this basis. Porcelain jacket crow ns take tw o hours plus laboratory charge. D etachable post crow ns take one hour and th irty m inutes plus cost of m a terial. D ev italizatio n and root canal fillings take one and one-half hours for anterio r teeth and tw o and one-half hours for posterior teeth. T h is should be rem em bered p articu larly by those who do not charge for treatm en ts. A fee of $10 for devitalization and root canal fillings of an terio r teeth and $15 for posterior teeth is the m inim um th a t a dentist can charge. Synthetic porcelain fillings take about the same tim e as simple am algam s, and should be charged for in the same p ropor tion as simple am algam s. T h e average cleaning of teeth takes tw enty-five m inutes, and the tim e value is the same here as it is for simple am al gam fillings. T h e average extraction, under a local anesthetic, takes fifteen m inutes, and the m inim um fee for th a t should be $2. E x tractio n s cannot be sold only on the basis of tim e consumed. T h is being a surgical operation in w hich the operator often assumes a g reat responsi bility, the fee m ust be com m ensurate w ith the seriousness of the case. N ev er theless, good ju d g m e n t m ust be used, and exorbitance m ust be avoided in establish ing the fee fo r this type of w ork. T h e average cem ent base takes tw enty m inutes and the m inim um fee th a t can be charged for a base is $2.75. A ll tre a t
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m ents, such as sealing in remedies for re lief of toothache, packing and irrigation, take fifteen m inutes on the average. A charge of $ 2 for each such trea tm e n t should be made. T h e fees ju s t discussed here have been calculated to fit the operations m ost com m only perform ed by the general p racti tio ner of dentistry. T h ey are based upon the value of tim e and m aterial plus the d en tist’s living wage. W h ile the figures quoted are perhaps n o t universally iden tical, they may still be used as a guide for m aking estim ates by the average p racti tioner, because the variations th a t m ight be ascribed to geographic location and personal adeptness of different dentists are too sm all to be of any significance. Besides, there is always room fo r using discretion in dentistry. I t may sometimes be necessary to give aw ay certain things at cost, or below cost, but w ith a definite know ledge as to the value of the gift, one is in a position to give know ingly and for a purpose, ra th e r th an unknow ingly and purposelessly. B ridgew ork and plates bring the high est revenue to the general p ractitioner of dentistry. T o use Boyd S. G a rd n e r’s ex pression, “ they make bread and b u tte r for the d entist,” and this presentation could n o t be considered com plete w ith o u t an analysis of this phase of dental practice and its fees. W ith regard to quoting of fees for this type of w ork, there is one particu larly cherished idea of th e average dentist th a t he m ust forever abandon. T h is idea is erroneous and im practical— it can even be considered a violation of professional ethics, although the practice of it has been follow ed by the finest and most ethical dentists. T hese dentists entertain the no tion th a t the deficiency in their incomes created by low fees received for operative den tistry can be made up on bridgew ork
and plates. If the idea of m aking one class of patients pay for the other can be justified from th e standpoint of profes sional ethics, w ould it n ot be b etter ethics to m ake the operative patients pay for the prosthetic p atien ts? P atien ts requiring operative d en tistry such as fillings, inlays and treatm en ts are generally young peo ple in good h ealth , self-dependent and able to pay. T h e n atu re of the dental w ork th a t they require is very beneficial to them , fo r it tends to preserve their n a tu ra l organs of m astication. I t is the hardest and most exacting branch of den tal practice, often dem anding the oper a to r’s utm ost physical and nervous exer tion. P atien ts req u irin g plates and bridges are generally old people, depend ing on someone fo r th eir m ere existence. T h e natu re of the d ental restorations th a t they require cannot be com pared in use fulness to th a t of the restored n atu ral teeth of th e younger patients. A lthough the d en tist does not have to exert him self n early so much in the con struction of dentures or removable bridgew ork as he does in operative pro cedures, it is an alm ost universally accepted axiom, as far as the dental pro fession is concerned, th a t artificial res torations have a higher pecuniary value than operative w ork, and it is expected th a t the sm all percentage of patients in need of artificial restorations pay the bill of the very large n um ber of patients in need of fillings and treatm ents. A n actu al count of h ours spent on the various operations and procedures in the average d ental office shows definitely and conclusively th a t the high fees received for prosthetic restorations do n ot make up for th e low fees received fo r fillings and treatm ents, and w h eth e r the idea of m aking up the losses sustained on one class of patients by overcharging another class of patients is ethical or not, it cer-
H onoro ff— Proper Fees for Average D entist tainly is a blunder from the standpoint of economics. A n inventory of dental operations per form ed by me th ro u g h o u t each year for the past six years reveals the fact th a t 75 per cent of the o p era to r’s tim e is spent on operative w ork, and only 25 per cent of his tim e is spent on prosthetic w ork. T h e average dentist distributes his 1 , 0 0 0 w orking hours in th e proportion show n in the accom panying tabulation. D
285 300 120 100 500 200 175 90 300
is t r ib u t io n
of
W
o r k in g
H
ours
( 1 ,0 0 0 )
H ours O perations a y e ar am algam fillings .........................115 synthetic porcelain fillin g s .. . 100 gold inlays and fillin g s............. 200 copper cem ent fillin g s............... 33 treatm en ts ................................... 120 prophylaxes ................................ 75 extractions ............... .................. 42 M a d e -o v e r fillings .......................... 5 copper cem ent b a se s................. 30 roentgenogram s ......................... 20
Per Cent 11.5 10.0 20.0 3.3 12.0 7.5 4.2 0.5 3.0 2.0
I n all, he spends ab o u t 750 hours in fillings, treatm en ts and extractions of teeth, and only about 250 hours in the m aking and insertion o f plates, crow ns and bridgew ork. In m ost cases, the dentist w ho is accus tomed to receive very low fees for opera tive w ork is also receiving proportionally low fees for plates and bridges, thus autom atically sh u ttin g him self off from the opportunity of m aking up his losses. B u t g ran tin g th a t he does receive a fair price for bridges and plates, w hich is about $15 an hour gross, according to all available inform ation as to the best aver age fee for this type of w ork, w ill this additional income of th e 250 hours m ake up for the loss incurred by underselling the 750 hours? T a k in g $10 as the m inim um gross value of a den tist’s productive hour, w hich is about the correct value, and assum ing th a t he charges only $5 an hour
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gross fo r his operative w ork, he loses $3,750 on th e 750 ho u rs of th is type of w ork a year. T h e 250 hours of pros thetic w o rk a t $15 an h o u r w o u ld b ring him an additional profit of $1,250 a year. D educting the $ 1,250 profit from the $3,750 of loss, he still has a loss of $2,500 a year w hich w as n ot offset by the addi tional $1,250 realized from bridges and plates. T h e approxim ate loss to the d ental profession of this country from insuffi ciency of fees is close to $150,000,000 a year. By m ak in g a proper charge for opera tive w ork, the dentist w ill preclude the necessity of m aking an excessive charge for prosthetic w ork, thus doing the rig h t th in g by both classes of his patients and also by himself. In justice to the average dentist, it m ust be said th a t he actu ally is not over stepping the boundaries of the code of ethics by g ettin g a b etter fee per h o u r for prosthetic w ork. W h a t little additional income he does get from bridge and plate w ork does n o t accrue from overcharging on this w ork. T h e larg er revenue here is really the result of economy in tim e m ade possible by the em ploym ent of o u t side labor. By delegating the d ental technician to do a large p o rtion of this w o rk for him, the dentist is enabled to finish these cases in a com paratively sh o rt tim e. W e re he to do all of his lab o rato ry w o rk himself, the fee for this class of w o rk w ould not be big a t all, as it w o u ld necessarily be spread o u t over many m ore hours than it now is. T h e fact th a t the deficit created by underselling 75 per cent of his tim e can not be absorbed by th e proper fees re ceived by the dentist for 25 per cent of his tim e cannot be em phasized any too strongly. T h e average dentist m ust dis
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pel a ll illusions as to th e possibility of counterbalancing operative losses by pros th etic gains. T h e only proper w ay to stop the losses on operative dentistry is not to incur them . L e t th e fees for pros thetic appliances stand w here they are, and le t the 75 per cent of patients w ho need operative w ork pay for this w ork in a m easure th a t w ill not create any deficit. C O N C L U S IO N
I t should be repeated th a t the item of cost can easily be arriv ed at by the use of the sim plest m ethods of accounting. I t m ust alw ays be rem em bered th a t every h o u r spent in the office on patients w h eth er it be in stopping a toothache, taking impressions or soldering a bridge, has a definite cost, and th a t these hours m ust be sold at a profit. I t is on the know l edge of the exact cost to him of each and every dental operation th a t the success of the dentist depends, and not until the average dentist takes the trouble to find o ut th a t cost w ill he be able to extricate himself from his financial difficulties.
T h is know ledge w ill change th e w hole psychologic aspect of the dentist. I t w ill cure him of a chronic in ferio rity com plex, w hich w as brought on by the con sta n t u n certain ty of his ground in the m a tte r of fixing of his fees. H is physiog nomy w ill be rid of blushing, and guess ing w ill become foreign to his m akeup. H e w ill begin to m ake charges fo r his w o rk intelligently. H e w ill stop “ th ro w ing” things in, and he w ill be placed in a position enabling him to nam e his fees w ith a certainty of m anner th a t com m ands confidence an d respect. H e w ill at once find o ut w hich operations do not pay, and he n atu ra lly w ill p u t them on a paying basis. H is fees w ill become u n i form and in direct proportion to his service. A ll of his patients w ill receive not only ethical professional treatm en t, b u t also ethical business treatm en t. H is income w ill be increased, n ot because of overvaluation of services, b ut because of stopping unnecessary extravagance in the dispensation of tim e, and because of re ceiving a fee w hich is adequate and prop erly due him.
SCIENTIFIC A N D R A T IO N A L THERAPEUTICS: ITS EFFECT O N D EN TAL PROGRESS* By P. J. HA NZLIK, M.D., San Francisco, Calif. H E subject, w hich has been assigned to me, “ Scientific and R ational T h erap e u tic s: Its E ffect on D e n ta l Progress,” implies th a t there is another
T
*Read a t the first general m eeting of the C hicago D ental Society, M id w in ter Clinic, Feb. 2, 1931. *T he papers of D rs. H anzlik, Smith and P a lm e r w ere presented as a sym posium on “ N ostrum s and P ro p rie ta ry Rem edies in D en tistry .” Jour. A. D. A., April, 1931
kind of therapeutics w hich is n eith er sci entific nor rational and may have undesir able influences. I t is know n th a t the treatm en t of disease is frequently dis posed of w ith a peculiar species of in d if ference and carelessness and th a t there is a large body of remedies of doubtful value whose use is inconsistent w ith ac cepted scientific principles. T h is is not surprising w hen one considers th a t the
H E term “ average den tist” is too often used rath e r vaguely and loose ly, and since I shall employ it from tim e to tim e as describing a certain defi nite individual, or a group of individuals, an effort w ill be m ade to w ard a clear understanding as to the m eaning of this term . Because of the complex hum an factors th a t m ust necessarily en ter into the ethical practice of dentistry, it w ould be impossible to point o u t certain groups of dentists, and classify them as superior, average or inferior, in accordance w ith the discharge of their professional obliga tions to their patients and w ith their ability to carry out the necessary tech nical procedures. I t is all too obvious, and the instances are too num erous to require any proof fu rth e r th an the con tention th a t m any of the so-called w iz ards and superm en of the profession are very often not up to par, either in their ability or the desire to do the proper thing by th eir patients. O n the oth er hand, it has been am ply dem onstrated th a t some of the finest dental operations and the m ost laudable self-sacrificing perform ances for the benefit of dental patients have come from dentists of a very hum ble and unassum ing type, whose names nearly always rem ain in obscurity.
T
*Read before the Section on D ental Eco nomics a t the M id w in ter C linic of the C hi cago D ental Society, Feb. 3, 1931. Jour. A. D. A-, April, 1931
T h e average dentist, then, should be looked on and accepted not as a dental p ractitioner of average ability, or of ability below the grade of those w ho are considered or wish to be considered as of high standing. R ath er, he should be judged by the caliber and social standing of his patients. H e is an average dentist w ho conscientiously, and to the best of his ability, m inisters to the d ental needs of the average citizen, of average means and of average requirem ents. T h e “av er age d en tist” can be considered only as here defined in the attem p t to arrive at a certain figure w hich may be looked on as his proper fee. A ll observations and con clusions in connection w ith the gaging of this fee can be based only upon the social standing and m aterial needs of the aver age dentist. I t is only these tw o condi tions, and not his professional standing, th a t make it necessary for the dentist to accept cash paym ent for his service. As a m em ber of m odern society, the average dentist cannot consider himself an exception to the rest of the com m unity in w hich he lives and carries on his w ork. H e is not im m une to the needs and obli gations w hich affect the social stru ctu re su rrou n d in g him, and he is subject to all economic rules and regulations which are imposed on all average citizens. H e is required to pay ren t and taxes. H e m ust pay fo r food, clothing, light, power, labor and m aterials in the same m anner as
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H onoro ff— Proper Fees for Average Dentist the rest of the com m unity; and he th e re fore m ust purpose to receive as rem u n era tion for his efforts, along w ith the satis faction th a t comes from giving good professional service, a m aterial rew ard w hich w ill enable him to m eet his obliga tions honorably. T h e pleasure th a t comes to the dentist from the realization th a t he has served w ell and from the g ratitu d e of his pa tients w ho are m ade happier through his service is not only the im pelling force w hich inspires him to do his w ork w ell but also the spiritual rew ard for the many sacrifices w hich he m ust make in the conscientious perform ance of his profes sional duties. T h is feeling of pleasure, although essentially a rew ard, cannot be governed by economic form ulas, cannot be evaluated in a pecuniary sense, and no attem pt shall be made here to set a price on it. O n e m ust be imbued w ith certain ideals and aspirations before one can u n dertake the proper practice of dentistry. Indeed, the situation w ould be ideal if the dentist could give himself entirely to serving hum anity in his especial ca pacity w ith o u t ever having to th in k of m aterial compensation. T h is ideal condition has not yet a r rived. T h e average dentist still finds him self in a w orld w hich is m aterialistic, sophisticated and hard-boiled, and in o r der to facilitate the proper functioning of his professional body and m ind, he m ust arm himself from head to foot w ith protective elem ents. H is resistance can be much strengthened by the injection of large doses of economic principles into his system. Society is expecting the dentist to fu l fil his mission in life. I t expects him to relieve pain, prevent disease and cure the afflictions w hich verily endanger lives, but it also dem ands, in no uncertain
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term s, th a t he pay his bills. If he does not satisfy dem ands for paym ent, this hum an benefactor is uncerem oniously dealt w ith by the same society for w hom he w orks so hard, and whose health and w elfare are his constant concern. T h ese objects of his professional devotion w ill shut off his w ate r and gas supply. T h ey w ill disconnect his telephone and shut off his light. T h ey w ill even p ut him o ut in the street, and take his home away, should he dare not to pay his bills. W ith all these dangers th reatening him, the dentist cannot loosen himself from the iron grip of m aterial dem ands and circum stances. H e is forced to aban don his ideas of p ure m issionary service, and he m ust mix business w ith his pro fession. T h e role of business m an is forced on him by society, and contrary to professional traditions, he m ust assume the position of salesm an, and consider his patients as custom ers in connection w ith the practice of his profession. In the same light, the dentist m ust consider himself an employe, and his patients have to be viewed as his employers. So, w h eth er he likes it or not, the average dentist is doctor, salesman and laborer all in one, and in his daily life he m ust conduct him self in a m anner th a t w ill satisfy all w ho have placed him in these three categories of hum an endeavor. H e m ust ad ju st him self to conditions as they are. H e m ust be able to solve his w orldly dilem m as in a practical way. G ra n tin g th a t his service is satisfac tory, his patients, having paid him w h at he him self has designated as a fee for th a t service, are justified in thinking th a t the dentist has been fu lly rew arded, and they have a rig h t to expect him to be able to m eet his financial obligations to them . W h y , then, is it th a t m any dentists are unable to pay th eir bills? W h y is it, then, th a t, according to the best in fo r
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m ation obtainable, th e n et yearly income of the average dentist in the U n ited States is less th a n $ 4,000? W h y is it th a t 50 per cent of the dental profession are delinquent in paying their d en tal sup ply bills? T h e fa u lt certainly is not w ith the public. T h e y are paying the dentist w h at he is asking them to pay, and th eir obli gations to him are apparently discharged honorably. F rom this, it follow s th a t the fee, o r the financial aw ard, set by the dentist himself fo r his w ork has been in adequate and insufficient to cover his necessary expenditures. T h e dentist, then, m ust look upon him self as the cause of his financial troubles, and he m ust m ake a thorough search w ithin the realm s of his ow n being, and th e confines of his ow n practice to find o u t w h at he him self does th a t is placing him in an economic predicam ent. H e m ust, first of all, fam iliarize him self w ith the various factors and principles th a t govern and determ ine com pensation for professional service. H e, also, m ust con d u ct his office and practice is strict accord w ith those principles. A s has been pointed out, the average d entist is n o t only a w age earner, but also the head of a business institution, and as such he is entitled, as economists rec ognize, to a re tu rn purely from th e sale of his product. T h e allotm ent of his fee, then, should be governed not alone by his necessities, com forts and luxuries, w hich are the m ain forces in the determ ination of a lab o rer’s w age. In the distribution of its w ealth, society m ust allow a share for the average dentist w hich is large enough to provide fo r all the three factors m en tioned, and also to cover all expenses in cidental to the ru n n in g of a d ental office, including interest on capital invested, de preciation and some net profit. T h is net
profit m ust be am ple enough, w hen set aside for th a t purpose, to provide a fair income for th e d en tist in his declining years, w hen he is no longer able to w o rk . T h is portion of the public w ealth so allotted to the dentist may be term ed as his fee. T h is sort of fee, to be considered p ro p er, does n o t necessarily have to be too high, b ut it m ust be sufficient. Such a fee is h ealth fu l for both patien t and den tist. A low fee makes it prohibitive for the den tist to do good w o rk and a high fee makes it prohibitive for the average patien t to have good w o rk done. In this respect, fees exert the same influence on dental service as do wages on labor, and economic law s th a t are applicable to labor are also applicable to d ental service. Both dentist and lab o rer are hum an, an d they are governed equally by the dictates of hum an n atu re. P ro f. R ich ard T . E ly, of the d ep art m ent of political economy of th e U n i versity of W isconsin, points o ut very vividly the favorable effect th a t good wages have on efficiency in labor. H e says, am ong oth er things : E ven from the standpoint of em ployers as a class, the policy of depressing of thè lab o r e rs’ sta n d a rd of life stands condem ned. M ore and m ore businessm en are com ing to lea rn the “economy of high w ages,” a n d th a t “cheap lab o r is d e a r labor.” A m erican labor is in m any industries the cheapest lab o r in the w orld, because it is the best paid. H igh w ages m ake possible a high sta n d a rd of life. T h e high sta n d a rd of life m akes the lab o re r intelligent, hopeful and full of c h a r acter, as well as m ore efficient physically. T h e increased efficiency m akes possible the h ig h er w ages. T h u s, by action and reaction the sta n d a rd of life is both a cause and result of w ages received.
I t is plain, then, th a t in order for the dentist to give him self w holeheartedly to his w ork, he m ust be paid fo r it in such m easure th a t he w ill n ot be kept in constant w an t. T h e dentist w ho earns a
HonorofJ— Proper Fees for Average D entist mere starv atio n income by the practice of his profession cannot be much enthused over dentistry, and w here th e re is no en thusiasm , there can be no good w ork. L ack of enthusiasm leads to a g rad u al dislike for th e profession, w hich is fol low ed by resentm ent on the p a rt of the dentist to w ard good w ork. T h e inevita ble result is b itter disappointm ent to the dentist and to his friends. As has been shown, his fees have a tre m endous influence on the life and be havior of the dentist, and therefore their determ ination cannot be taken too lightly by him . Still, a study of dental fees as they are today shows definitely th a t thou sands of dentists are n o t giving this m at te r any th o u g h t a t all, and resort mostly to guessw ork and tru s t to luck in setting a fee fo r their w ork. I n looking thro u g h the m any lists of prices for dental w o rk th a t have been gathered by investigators for various d en tal organizations and publications in the past tw o or three years, one glimpses a tragic picture. T hese figures te ll a sad story of how thousands of intelligent, w ell-intentioned and industrious people engaged in th e practice of dentistry are daily com m itting economic suicide. T h e y tell of inverse proportions betw een serv ice and fees, they show vividly th e incon sistencies and lack of application of sim ple logic on the p a rt of a g reat m ajority of dentists to the m a tte r of estim ating costs of dental service. T h ese figures leave nothing to the im agination as to the m any sacrifices and self-denials th a t these grossly underpaid dentists have to contend w ith as a result of th e ir own m ism anagem ent. T h e re is no good reason th a t there should be a state of constant economic depression in the ranks of the dental pro fession. M o st patients pay th eir bills as estim ated and required by the dentist.
619
T h e fact th a t the d en tist underestim ates his ow n services an d presents an insuffi cient bill is en tirely u nknow n to them . As a m a tte r of fact, m any patients w ould consider it a personal insult to learn th a t their d en tist had been giving them charity. I t is plainly th e business of the dentist to be able to present the rig h t kind of a bill fo r his services. B u t so far, the dentist has been slow in acquiring know l edge in this respect. Instead, he has ac quired a lo t of bad hab its th a t a re u n d er m ining his financial stru ctu re. Q u ite unnecessarily, and m uch too often, m any dentists play the role of “ big b ro th er” and “good fellow ” in the w ro n g place, and confer uncalled for philanthropies. E ven the best inform ed dentists can recall m ore th an one instance in th eir ow n practices in w hich the show ering of professional ch arity on patients has been accepted by the p atien ts w ith w o n d er m ent as to the soundness of the d o cto r’s m ind. C hief am ong the bad habits of the den tist leading to his financial plight is his indulgence in “ th ro w in g in ” things w ith his w ork as a bonus. O ne w onders if any dentist can w alk into a m erchandise store, purchase a h at and have a p air of shoes “ th ro w n in ” w ith the bargain. T h e very th o u g h t of it w ould be absurd. Y et, m any dentists w ill th in k n o thing a t all of “ th ro w in g in ” a prophylaxis w ith each operation they u n dertake, be th a t operation as sm all as the placing of tw o am algam fillings. M an y w ill undertake the construction of a ru b ber den tu re for a certain fee, and w ill unhesitatingly “ th ro w in ” all the extrac tions th a t m ay be required in connection w ith th a t p articu la r case, w ith o u t any additional charge. Still others w ill “ th ro w in ” all necessary treatm en ts for
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the fee w hich they are accustom ed to charge for the filling or crow n th a t the treated tooth may require. P oor judgm ent, undervaluation of th e ir services and guessw ork are also largely responsible for the financial dow n fall of m any dentists. T h is is perhaps best illu strated by a story told by a past president of the Chicago D en ta l Society of how! a colleague of his m ade a trip to his office in the Chicago loop d istrict from his suburban hom e on Sunday m orning, and afte r spending the w hole m orning in relieving the pain from an incipient alveolar abscess fo r a m illionaire’s little son, nearly knocked the boy’s fath er off his feet w hen he nam ed his fee. “W h a t do I ow e you, D o c to r? ” asked the pa tie n t’s father. “ I appreciate g reatly the fact th a t you p u t yourself out fo r me, and I see you have w orked very h a rd .” “ W e ll,” said the doctor, hesitatingly, afte r some deliberation, “ I guess $ 2 w ill do.” T h is m an sold four hours of his tim e and $ 2 w o rth of railw ay tickets for the sum of $ 2 , besides spoiling the holiday fo r him self and a friend w ith whom he had an appointm ent to play a round of golf th a t m orning. Such poor logic as w as used by this dentist in th e fixing of his fee and sim ilar dem onstrations of undercharging by other dentists are not only detrim ental to the earn in g pow er of the profession, but w h at is m uch w orse than th at, they tend to belittle dental service in the eyes of the laity. H ere and there, a case of dispro portion can be observed, w hen the den tist has p u t too high a value on his serv ices, or has received large sums of money for very little service.’ T hese m en are, of course, the exception, and aside from m entioning th a t there is no room in the ethical practice of dentistry fo r exorbit a n t fees and th a t extortion is n o t a virtue in the professional m an, the discussion
of the m a tte r can be abandoned w ith a feeling of gratification th a t extortionists and quacks are only in a sm all m inority. T h e ir m ethods and fees should have no influence w hatev er on the average dentist. A ll of th e undesirable traits of the average dentist m entioned are to be con sidered as co n trib u to ry causes of dim in ished income and microscopic fees. T h e m ain underlying cause for inade quate d en tal fees is to be found in the lack of know ledge on the p a rt of the aver age dentist of th e actual cost to him of the various types of restorations, opera tions and services for w hich he is called on in his daily practice. A ll available figures, w h eth er ob tained from c u rre n t dental publications, from statistics gathered by bureaus of dental economics o r from piles of data gathered by the dental supply houses, point to one thing, and th a t is th a t the average dentist has a net annual income of less th an $4,000. T h is figure being an average, it follow s, natu rally , th a t there are still thousands of dentists whose net ann u al income is less th an $3,000. If th a t is tru e, th e fees charged by th o u sands of dentists, as shown in m any of the d ental m agazines, are correct. I t m ust be tru e, then, th a t thousands of dentists are m aking a charge of $2 for a one-surface am algam filling, and $3 for tw o surface am algam fillings. T h ese low fees are prim a facie evidence th a t the dentists m aking those charges have abso lutely no idea as to w h at those fillings cost them . T h e fact th a t thousands of dentists are m aking one-surface gold in lays for a fee ranging between $5 and $ 1 0 and tw o-surface gold inlays fo r a fee ranging betw een $7 and $12 is more evidence of the u tte r disregard for the cost of these restorations to the dentist. E ven those dentists who report fairly good incomes show a great need of better
H onoro ff— Proper Fees for Average Dentist und erstanding of the basic economic p rin ciples affecting their fees. P erhaps the m ost autho ritativ e and authentic figures along the lines of fees charged, gross incomes and expenses are to be found in the prelim inary report issued by N o rth w estern U niversity D e n ta l School B ureau of Economics, of a survey for 1929. T h is survey is very valuable. I t reached out to all states and gathered d ata from N o rth w e ste rn alum ni w ho have been in active practice fo r from one to th irty or m ore years. T h e m a jo rity of d ata given in this report w ere obtained from dentists practicing in cities th a t have a population of from 1 0 , 0 0 0 to 500,000 or m ore. T h e figures appearing in the survey w ere subm itted only by oneth ird of the dentists w ho received ques tionnaires. T h ese figures show only large incomes, w hich makes it apparent th a t they w ere given out by successful prac titioners, w ho are w ell paid and whose offices are conducted m ost efficiently. T h e figures could be considered average incomes had the other tw o -thirds of the alum ni sent in their reports. B u t those w ho do not bother answ ering question naires are, generally, m en w ho either have to guess at figures o r whose incomes are so poor th a t they are shy to disclose th eir identity. N atu ra lly , the average annual net in come of $5,480 earned by one-third of N o rth w estern alum ni cannot be consid ered as a typical net ann u al income of the average dentist. T h is figure w ould no doubt be brought dow n to less than $4,000 had the m en receiving the low fees reported their actual incomes to the bureau. T h e rep o rt of the bureau is highly significant because it brings out the follow ing facts: 1. T h e best paid men in the country earn less than $ 6 , 0 0 0 a year net on the average. 2. T h e most efficient men in the country show a m axi
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m um of 1 , 2 0 0 productive hours a year. 3. T h e gross expense of the m ost efficient dental offices is about 35 per cent of the gross income. 4. In o rd er to earn $6,000 a year, p u ttin g in the m axim um num ber of hours hum anly possible to w ork by a dentist, w hich is 1 , 2 0 0 hours, he m ust receive a fee of not less th an $ 8 an hour. 5. T h e uniform stan d ard of life of those dentists as reflected by the uniform ity of their fees can be accepted as the standard of life of all average dentists. C onsidering the social environm ent of the dentist, it is to be observed th a t he cannot live any too extravagantly on $500 a m onth, and no dentist need fear th a t his fees are too excessive if he sets o u t to earn $500 a m onth. A t a m ini m um , the average dentist has only 1 , 0 0 0 gainful hours a year, and the office ex pense of the average dentist is 40 per cent of his gross income. T o arriv e at a fee of $ 6 n et an hour, th e average dentist m ust charge $ 1 0 gross an hour. O n e m ust take into consideration the fact th a t the num ber of years of a den tist’s m axim um production are very few. I t takes some years be fore one a ttain s m axim um production, and having reached the top of his ability to produce, one m ust reckon w ith the physical impossibility to m ain tain top speed indefinitely. T h e num ber of active years th a t the average dentist has for the practice of his profession can be divided into three periods. T h e first are the years given to the building up of his p ractice; the second, th e years d u rin g w hich the zenith of his professional achievem ent has been rea ch ed ; the th ird is m ade up of those years d u rin g w hich his practice m ust assume a dow ngrade course. I t is clear, then, th a t the period of m axim um production m ust give the dentist a revenue w hich should be a m p k to m ake up fo r the insufficient income of
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the years previous to and follow ing those of m axim um productivity. Since he has only a very short tim e in w hich he can receive fu ll financial rew ard for his pro fessional efforts, the dentist cannot af ford to w aste th a t tim e. H e m ust use it sparingly and judiciously as som ething very precious, as the only th in g on w hich depend his own happiness and the hap piness of his fam ily. H e m ust learn the actu al value of his tim e in dollars and cents, and he m ust learn to apply th a t tim e value to the cost of the various pro cedures, operations and restorations for w hich he is called on in his daily practice. T o express this in term s of business: P atients come to the dentist to buy fill ings, crowns, inlays, plates, bridges, etc. T h e dentist, w ho sells those things, m ust know their exact cost. L acking in the know ledge of cost, he cannot sell his com m odity rightly. H e is a p t to charge either too m uch or too little* doing an injustice either to him self o r to his patients. I t so happens th a t m ost dental opera tions and procedures are of a character th a t allow s of a certain definite am ount of tim e to be apportioned to each one of them . T h ey can practically all be meas ured in tim e units, w hich makes it pos sible to affix to them a certain definite financial value. A ll th a t one has to do is to m ake use of th e sim plest form of record keeping and the sim plest rules of arithm etic. H av in g m ade a hundred onesurface am algam fillings, and having kept stric t record of the tim e taken up by these fillings, the dentist can find out for him self the average length of tim e th a t he spent in th e m aking of an am algam fill ing, by dividing the to ta l num ber of hours by the num ber of fillings. T h e same m ethod can be applied to th e gold inlay, to the various types of crow ns, to tre a t m ents, to synthetic porcelain fillings, etc. H av in g determ ined th e average length
of tim e required by each operation, the dentist m ust n ex t m ake it his business to find o u t the cost to him of th a t tim e in actual cash. T h is he can do by dividing the to ta l an n u al office expense by the num ber of hours he actually w orks at the chair and in th e laboratory. F o r example, if he w orks the m axim um of 1 , 2 0 0 hours a year and his gross office expense is $3,600, each w orking h o u r has a cost value of $3. T h is cost per hour, by the way, is applicable to all average dental offices. T h e d en tist w ho only w orks 1 , 0 0 0 hours and has a gross expense of $3,000 is also paying $3 an hour for the privilege of practicing dentistry. A pply ing this tim e value to the simple occlusal am algam filling, one can easily arrive at the cost to him of th a t operation. F rom statistics com piled by me, it can be said w ith a fair degree of exactness th at, on the average, it takes twenty-five m inutes to m ake a simple occlusal am algam fill ing, using proper m ethods of cavity prep aration and including polishing. Since the low est cost to the average dentist of doing business is $3 an hour, tw enty-five m inutes of his tim e costs the average den tist $1.25. A dding the cost of m aterial, w hich is 15 cents, to the tim e value, it is established th a t the simple occlusal am al gam filling costs the dentist $1.40. T h e dentist w ho sells these fillings at $ 2 is getting a fee of 60 cents fo r tw enty-five m inutes, or $1.40 an hour. If he w ere to m ake n o thing b u t simple occlusal am al gam fillings all th e year ro u n d a t th a t rate, he w o u ld have a m axim um annual net income of $1,680, or $35 a week, which, of course, is a very poor w age for a pro fessional m an. A t $3 fo r each simple occlusal am algam filling, the net fee for each ho u r w o u ld be $3.84 and the m axi m um net an n u al income w ould be $4,608. A t $ 4 for each simple occlusal am algam filling, the net fee for each h o u r w ould
Honoroff— Proper Fees for Average D entist be $6.24, w hich is about the rig h t fee for the average dentist. T h e actual cost to the den tist of the gold inlay is established in this m anner. I t takes on the average one and threeq u arte rs hours to produce a gold inlay, using proper cavity preparation, im pres sion taking, casting, polishing and setting. T h is tim e has a cost value to the dentist of $5.25, the m aterial used has a value of $1. In all, the gold inlay has a cost value to the dentist of $6.25, on the average. T h e dentist w ho makes gold inlays a t $5 is giving his labor for nothing, and be sides he is paying his patients $1.25 in cash as a bonus fo r being allow ed to prac tice his a rt in the m ouths of those patients. T h e dentist w ho makes gold inlays for $6.25 is ju s t w orking fo r nothing, b u t is not giving his patients any “ pocket m oney.” T hose men w ho m ake gold in lays at $ 1 0 , and there are m any in this class, are earning a net profit of $3.75 fo r each inlay, or $ 2 an hour, and those w ho get $15 for each gold inlay are m ak ing about $5 an hour net. T o m ake a net profit of $ 6 an h o u r on gold inlays, one has to charge $16.75 for the average in lay. I t is peculiar but tru e th a t the men w ho m anage to get $3 fo r each simple occlusal am algam filling, thus earning close to $4 an hour net, are selling gold inlays a t $ 1 0 or less, prices w hich bring them only $2 an hour or even less. I t is logical to expect th a t a gold inlay restora tion, w hich requires finer taste and bet te r skill, and m ore intense application of the o p erator’s resourcefulness, should com m and a b etter fee than does the sim ple am algam filling; still, the tim e con sum ed by the gold inlay is sold by the m ajority of the profession for a half of the price th a t they are getting for the tim e used up by the am algam filling.
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T h is condition can be attrib u ted only to the fact th a t m ost dentists do not know the value of the inlay. T h e y seem to base their charges only on the cost of m aterial, fo rg ettin g the cost of time. G o ld crow ns take about the same am ount of tim e an d m aterials as inlays, and the fee for gold crow ns should be the same as the fee fo r inlays. T h re e-q u arte r crow ns take tw o hours, and $1.50 w o rth of m aterials, and the fee for them should be figured on this basis. Porcelain jacket crow ns take tw o hours plus laboratory charge. D etachable post crow ns take one hour and th irty m inutes plus cost of m a terial. D ev italizatio n and root canal fillings take one and one-half hours for anterio r teeth and tw o and one-half hours for posterior teeth. T h is should be rem em bered p articu larly by those who do not charge for treatm en ts. A fee of $10 for devitalization and root canal fillings of an terio r teeth and $15 for posterior teeth is the m inim um th a t a dentist can charge. Synthetic porcelain fillings take about the same tim e as simple am algam s, and should be charged for in the same p ropor tion as simple am algam s. T h e average cleaning of teeth takes tw enty-five m inutes, and the tim e value is the same here as it is for simple am al gam fillings. T h e average extraction, under a local anesthetic, takes fifteen m inutes, and the m inim um fee for th a t should be $2. E x tractio n s cannot be sold only on the basis of tim e consumed. T h is being a surgical operation in w hich the operator often assumes a g reat responsi bility, the fee m ust be com m ensurate w ith the seriousness of the case. N ev er theless, good ju d g m e n t m ust be used, and exorbitance m ust be avoided in establish ing the fee fo r this type of w ork. T h e average cem ent base takes tw enty m inutes and the m inim um fee th a t can be charged for a base is $2.75. A ll tre a t
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m ents, such as sealing in remedies for re lief of toothache, packing and irrigation, take fifteen m inutes on the average. A charge of $ 2 for each such trea tm e n t should be made. T h e fees ju s t discussed here have been calculated to fit the operations m ost com m only perform ed by the general p racti tio ner of dentistry. T h ey are based upon the value of tim e and m aterial plus the d en tist’s living wage. W h ile the figures quoted are perhaps n o t universally iden tical, they may still be used as a guide for m aking estim ates by the average p racti tioner, because the variations th a t m ight be ascribed to geographic location and personal adeptness of different dentists are too sm all to be of any significance. Besides, there is always room fo r using discretion in dentistry. I t may sometimes be necessary to give aw ay certain things at cost, or below cost, but w ith a definite know ledge as to the value of the gift, one is in a position to give know ingly and for a purpose, ra th e r th an unknow ingly and purposelessly. B ridgew ork and plates bring the high est revenue to the general p ractitioner of dentistry. T o use Boyd S. G a rd n e r’s ex pression, “ they make bread and b u tte r for the d entist,” and this presentation could n o t be considered com plete w ith o u t an analysis of this phase of dental practice and its fees. W ith regard to quoting of fees for this type of w ork, there is one particu larly cherished idea of th e average dentist th a t he m ust forever abandon. T h is idea is erroneous and im practical— it can even be considered a violation of professional ethics, although the practice of it has been follow ed by the finest and most ethical dentists. T hese dentists entertain the no tion th a t the deficiency in their incomes created by low fees received for operative den tistry can be made up on bridgew ork
and plates. If the idea of m aking one class of patients pay for the other can be justified from th e standpoint of profes sional ethics, w ould it n ot be b etter ethics to m ake the operative patients pay for the prosthetic p atien ts? P atien ts requiring operative d en tistry such as fillings, inlays and treatm en ts are generally young peo ple in good h ealth , self-dependent and able to pay. T h e n atu re of the dental w ork th a t they require is very beneficial to them , fo r it tends to preserve their n a tu ra l organs of m astication. I t is the hardest and most exacting branch of den tal practice, often dem anding the oper a to r’s utm ost physical and nervous exer tion. P atien ts req u irin g plates and bridges are generally old people, depend ing on someone fo r th eir m ere existence. T h e natu re of the d ental restorations th a t they require cannot be com pared in use fulness to th a t of the restored n atu ral teeth of th e younger patients. A lthough the d en tist does not have to exert him self n early so much in the con struction of dentures or removable bridgew ork as he does in operative pro cedures, it is an alm ost universally accepted axiom, as far as the dental pro fession is concerned, th a t artificial res torations have a higher pecuniary value than operative w ork, and it is expected th a t the sm all percentage of patients in need of artificial restorations pay the bill of the very large n um ber of patients in need of fillings and treatm ents. A n actu al count of h ours spent on the various operations and procedures in the average d ental office shows definitely and conclusively th a t the high fees received for prosthetic restorations do n ot make up for th e low fees received fo r fillings and treatm ents, and w h eth e r the idea of m aking up the losses sustained on one class of patients by overcharging another class of patients is ethical or not, it cer-
H onoro ff— Proper Fees for Average D entist tainly is a blunder from the standpoint of economics. A n inventory of dental operations per form ed by me th ro u g h o u t each year for the past six years reveals the fact th a t 75 per cent of the o p era to r’s tim e is spent on operative w ork, and only 25 per cent of his tim e is spent on prosthetic w ork. T h e average dentist distributes his 1 , 0 0 0 w orking hours in th e proportion show n in the accom panying tabulation. D
285 300 120 100 500 200 175 90 300
is t r ib u t io n
of
W
o r k in g
H
ours
( 1 ,0 0 0 )
H ours O perations a y e ar am algam fillings .........................115 synthetic porcelain fillin g s .. . 100 gold inlays and fillin g s............. 200 copper cem ent fillin g s............... 33 treatm en ts ................................... 120 prophylaxes ................................ 75 extractions ............... .................. 42 M a d e -o v e r fillings .......................... 5 copper cem ent b a se s................. 30 roentgenogram s ......................... 20
Per Cent 11.5 10.0 20.0 3.3 12.0 7.5 4.2 0.5 3.0 2.0
I n all, he spends ab o u t 750 hours in fillings, treatm en ts and extractions of teeth, and only about 250 hours in the m aking and insertion o f plates, crow ns and bridgew ork. In m ost cases, the dentist w ho is accus tomed to receive very low fees for opera tive w ork is also receiving proportionally low fees for plates and bridges, thus autom atically sh u ttin g him self off from the opportunity of m aking up his losses. B u t g ran tin g th a t he does receive a fair price for bridges and plates, w hich is about $15 an hour gross, according to all available inform ation as to the best aver age fee for this type of w ork, w ill this additional income of th e 250 hours m ake up for the loss incurred by underselling the 750 hours? T a k in g $10 as the m inim um gross value of a den tist’s productive hour, w hich is about the correct value, and assum ing th a t he charges only $5 an hour
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gross fo r his operative w ork, he loses $3,750 on th e 750 ho u rs of th is type of w ork a year. T h e 250 hours of pros thetic w o rk a t $15 an h o u r w o u ld b ring him an additional profit of $1,250 a year. D educting the $ 1,250 profit from the $3,750 of loss, he still has a loss of $2,500 a year w hich w as n ot offset by the addi tional $1,250 realized from bridges and plates. T h e approxim ate loss to the d ental profession of this country from insuffi ciency of fees is close to $150,000,000 a year. By m ak in g a proper charge for opera tive w ork, the dentist w ill preclude the necessity of m aking an excessive charge for prosthetic w ork, thus doing the rig h t th in g by both classes of his patients and also by himself. In justice to the average dentist, it m ust be said th a t he actu ally is not over stepping the boundaries of the code of ethics by g ettin g a b etter fee per h o u r for prosthetic w ork. W h a t little additional income he does get from bridge and plate w ork does n o t accrue from overcharging on this w ork. T h e larg er revenue here is really the result of economy in tim e m ade possible by the em ploym ent of o u t side labor. By delegating the d ental technician to do a large p o rtion of this w o rk for him, the dentist is enabled to finish these cases in a com paratively sh o rt tim e. W e re he to do all of his lab o rato ry w o rk himself, the fee for this class of w o rk w ould not be big a t all, as it w o u ld necessarily be spread o u t over many m ore hours than it now is. T h e fact th a t the deficit created by underselling 75 per cent of his tim e can not be absorbed by th e proper fees re ceived by the dentist for 25 per cent of his tim e cannot be em phasized any too strongly. T h e average dentist m ust dis
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pel a ll illusions as to th e possibility of counterbalancing operative losses by pros th etic gains. T h e only proper w ay to stop the losses on operative dentistry is not to incur them . L e t th e fees for pros thetic appliances stand w here they are, and le t the 75 per cent of patients w ho need operative w ork pay for this w ork in a m easure th a t w ill not create any deficit. C O N C L U S IO N
I t should be repeated th a t the item of cost can easily be arriv ed at by the use of the sim plest m ethods of accounting. I t m ust alw ays be rem em bered th a t every h o u r spent in the office on patients w h eth er it be in stopping a toothache, taking impressions or soldering a bridge, has a definite cost, and th a t these hours m ust be sold at a profit. I t is on the know l edge of the exact cost to him of each and every dental operation th a t the success of the dentist depends, and not until the average dentist takes the trouble to find o ut th a t cost w ill he be able to extricate himself from his financial difficulties.
T h is know ledge w ill change th e w hole psychologic aspect of the dentist. I t w ill cure him of a chronic in ferio rity com plex, w hich w as brought on by the con sta n t u n certain ty of his ground in the m a tte r of fixing of his fees. H is physiog nomy w ill be rid of blushing, and guess ing w ill become foreign to his m akeup. H e w ill begin to m ake charges fo r his w o rk intelligently. H e w ill stop “ th ro w ing” things in, and he w ill be placed in a position enabling him to nam e his fees w ith a certainty of m anner th a t com m ands confidence an d respect. H e w ill at once find o ut w hich operations do not pay, and he n atu ra lly w ill p u t them on a paying basis. H is fees w ill become u n i form and in direct proportion to his service. A ll of his patients w ill receive not only ethical professional treatm en t, b u t also ethical business treatm en t. H is income w ill be increased, n ot because of overvaluation of services, b ut because of stopping unnecessary extravagance in the dispensation of tim e, and because of re ceiving a fee w hich is adequate and prop erly due him.
SCIENTIFIC A N D R A T IO N A L THERAPEUTICS: ITS EFFECT O N D EN TAL PROGRESS* By P. J. HA NZLIK, M.D., San Francisco, Calif. H E subject, w hich has been assigned to me, “ Scientific and R ational T h erap e u tic s: Its E ffect on D e n ta l Progress,” implies th a t there is another
T
*Read a t the first general m eeting of the C hicago D ental Society, M id w in ter Clinic, Feb. 2, 1931. *T he papers of D rs. H anzlik, Smith and P a lm e r w ere presented as a sym posium on “ N ostrum s and P ro p rie ta ry Rem edies in D en tistry .” Jour. A. D. A., April, 1931
kind of therapeutics w hich is n eith er sci entific nor rational and may have undesir able influences. I t is know n th a t the treatm en t of disease is frequently dis posed of w ith a peculiar species of in d if ference and carelessness and th a t there is a large body of remedies of doubtful value whose use is inconsistent w ith ac cepted scientific principles. T h is is not surprising w hen one considers th a t the