Throughout the 1950s, most American dentists and physicians practiced in much the same environment: typically one office, one doctor, one assistant and one shingle (letters not to exceed three inches in height, please). Compared with today’s technology-driven, hospital-centered, intricately organized medical system, the 21st century physician would find this way of practicing impossibly quaint and impractical. And rightly so. No matter what nostalgia we may feel for the kindly family doctor who made house calls, he’s gone forever. Most physicians would not trade today’s MRI systems and automated labs and batteries of specialists for a black bag full of pill bottles.

Compared to this massive change in medicine, the dental practice model has changed remarkably little. Oh sure, we’re not quite the lonely individualists our predecessors were. We make greater use of auxiliary personnel. We rely increasingly on outside vendors to handle billing and collections and other "peripheral" tasks. But according to the most recent ADA survey, 64 percent of U.S. dentists are still solo practitioners. In short, while medicine has become industrialized, dentistry has remained a profession dominated by small, independent practices.

Why is this the case? Are we just behind the times? Or is there something about dentistry that does not lend itself to bigness? A little reflection provides at least part of the answer.

EVOLUTIONARY PRESSURES
Practice models evolve in response to economics, technology and what I’ll call "style"—the personal preferences of the practitioners and their patients. Leaving aside the last of these, it is clear that the explosive growth of medical technology in the last half-century has made the physician increasingly reliant on costly machinery for diagnosis and treatment. A simultaneous explosion of medical knowledge has led to a much-expanded role for the specialist.

It doesn’t take much of an economist to realize that a solo medical practice can’t survive in this environment without relying heavily on large, well-capitalized institutions with the ability to spread the cost of such a massive infrastructure. At first, traditional hospitals filled this role. Subsequent innovations—health maintenance organizations, preferred provider networks, specialty outpatient centers and the like—have been motivated sometimes by altruism, sometimes by profit, but almost always by economic factors. The M.D. has become just one link (and in economic terms, a minor player) in a long and complex "food chain."

To date, at least, dentistry hasn’t fit this mold. We, too, have made great strides since the 1950s with respect to our knowledge and our technology. Our ability to cure and rehabilitate our patients rivals that of any medical specialty, and owes much to sophisticated research. But the technology never became so expensive, nor the specialization so fragmented, as to force the creation of massive structures to deliver quality care. If "big dentistry" ever becomes the norm, it will be a matter of deliberate choice, not of necessity.

DENTISTRY’S DISTINCTIVE STYLE
So here we are, professionals in a field that demands entrepreneurism from the majority, not just a few at the top. That means thinking and acting like entrepreneurs. Assuming risks. Innovating. Planning. Experimenting. Developing a genuine personal relationship with each and every one of our patients. Taking responsibility for staff members who must rely on us for their livelihoods. Reaping the reward when things go well, and paying the price when they don’t. The entrepreneurial life is a daily challenge, but as a group, we dentists seem to enjoy the thrill.

This generalization is not, of course, true for every individual or every circumstance. Not everyone wants the hassle that comes with running a small business. And since some undertakings are of a scope that demands a more extensive organization (public health, the military and educational institutions come to mind), there are plenty of opportunities for dentists who prefer the role of employee to that of entrepreneur.

I, for one, have always been an employee of a dental school. I certainly don’t own the practice where I work; and even if I did, there would be no profit, by definition. Nevertheless, I am convinced that an entrepreneurial attitude is a great asset in every employee. We need to encourage entrepreneurial thinking (of an appropriate and realistic sort) by finding ways to solicit and reward good ideas.

I just hope that if we choose to go down the road toward bigness, we do so with our eyes wide open.

IS BIGGER BETTER?
What then of the future? Will the status quo persist for another 30 or 40 years? Or will dentistry follow the "medical model" away from small practices toward greater concentration and specialization?

There are three circumstances that might drive us in that direction. For one, there may be some spectacular breakthroughs in diagnosis and treatment that would necessitate centralized facilities and heavy capital investment. For another, new ways of delivering care may be imposed either by government fiat or by the cumulative force of litigation. Or third, we may voluntarily form ourselves into larger corporate entities.

I just hope that if we choose to go down the road toward bigness, we do so with our eyes wide open. Why, after all, should a dental practice grow beyond some rather modest size? The patient still has to be physically present; you can’t clean teeth over the Internet (at least not yet). Economies of scale make a real difference when you go from one to two dentists in a practice, but at some point—five? 10?—the savings dwindle and vanish as bureaucracy takes over. From there on, the major benefits of consolidation, if any, flow not to the dentist-employee, certainly not to the public, but to the necessarily restricted ownership group. I’d want to think twice about what I was giving up, and for what.

I think we all recognize that dentistry is a business—more than just a business, yes, but a business all the same. As such, it needs to be intelligently and responsibly managed. We need periodically to re-examine why we do what we do, and to ask ourselves if there are alternatives that would be better for our patients or for ourselves. We should never lose sight, though, of what we value in our professional life, or why we chose dentistry in the first place. Practice models from other fields should be viewed with considerable skepticism. One size does not fit all.