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Comment by edouard-harris | Hacker News Reader

Yup. In fact, a great hack is to go to an inexperienced dentist instead of an experienced one for routine work. The reason is that dentists who are fresh out of school are competent enough to do basic cleanings and checkups. But they haven't yet had time to accrete the expensive habits, and the little business optimizations that feed them, that highly-paid professionals often develop. I generally switch dentists every five years or so, and find that cadence works nicely.

(Source: a couple of my close friends are dentists and suggested this strategy.)

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Here in Germany it is actually the really old dentists that can be trusted. They were not raised to think business oriented. Though most of them have have retired by now.

My old childhood dentist used to do the absolutely necessary. He just cared about keeping my teeth healthy and not putting me under unnecessary stress. He did not even remove my wisdom teeth. When he retired the new doc would simply maximize the amount of procedures. One routine checkup and he would find ten things that needed to be done.

What had changed? In Germany doctors used to be basically paid from a fixed budged. In 2007 there was a health care reform changing that. Now they would be paid for individual procedures. So obviously doctors would try to do as much profitable procedures as possibles.

The articles misses the target a bit, probably because health care in the US has been run like a business for much longer so it is harder to see the real issue: It is not cultural, it is not some dentists being shady and it can not be fixed by educating dentists. It it the natural result of the incentives that are in place.

If you try to run health care like a business you will necessarily and always produce these issues. And this is not dentist specific. Lot's of unnecessary but profitable surgeries are being performed as well.

The best dentist I ever went to had a picture of his airline pilot wife on the wall - and from how he treated his patients and charged, I got the feeling he worked because he liked to, not because he needed to.

However, if you have a "flat fee" dentist/doctor you could be now encouraging the opposite - do the minimum work necessary to get done with the day. It's hard to legislate "be a caring, honest professional" but we can at least remove some of the incentives to not be.

> However, if you have a "flat fee" dentist/doctor you could be now encouraging the opposite - do the minimum work necessary to get done with the day. It's hard to legislate "be a caring, honest professional" but we can at least remove some of the incentives to not be.

First of all, we know that it does not encourage the opposite, see Germany pre 2007 or any other country where where health care is not run like a business but let's look into it in the abstract:

Humans love helping other humans. The "be a caring, honest professional" part is a product of intrinsic motivation. The idea that it needs to be externally motivated is extremely harmful. That is not how humans work.

Yes, some people get into medicine for the social status, the power or simply money but that is not the majority and we need to a way to filter out those that are full on narcissistic but the vast majority really just wants to help people.

> The best dentist I ever went to had a picture of his airline pilot wife on the wall - and from how he treated his patients and charged, I got the feeling he worked because he liked to, not because he needed to.

You hit the point here. He doesn't need any external drive to do his best, he just needed the opportunity.

It's similar to software developers wanting to write good code. They will strive to do so given the chance and ability even when management discourages and punishes them for that, as is often the case. (Well, "good code" might be subjective but you get the basic idea, humans want to do a good job.)

Yep, the hard part is going to be switching tracks from one to other, which will take an entire career (getting a dentist addicted to money to be satisfied with a moderate income can be hard) - which likely means that the change will come by classifying some "new kind of toothcare professional" that will slowly overtake.

My "really old dentist" drilled a whole straight through 2 teeth and didn't tell me after filling it up... It is just an anecdote (as is your account), but I now prefer a university clinic where young students are taught and most of the time keep working for a time there as well. Up to date techniques and they are not out for the big bucks yet.

Perhaps there is a U-shaped curve with the range being the desirable properties and the domain being years in operation. Young ones can often start with the MBA stuff, and I've experienced MD's who seem like they are about to retire by selling their practice to a whole army of MBA's, but in the meantime they don't just do stuff for the revenue.

> In Germany doctors used to be basically paid from a fixed budged.

Fixed budget for what? A patient or a case?

Per insured person.

So how this worked was that you couldn't just open shop wherever you pleased as a dentist but needed to get a "place". Basic calculation was: we need one dentist per x-people in an area to make sure everyone has access to one. So, as a dentist, you would try to get a slot or probably just take over an existing practice.

I will simplify it a bit but basically there is x-people paying insurance (health insurance is mandatory for nearly everyone) and we calculate how much it costs on average to provide health care for for one insured person (children are mostly insured under their parents so it is more like per family than person) and with that you allocate a budget on what to pay the dentist.

So basically if you were a dentists and you patients rarely ever needed to visit you, you were golden. You were incentivized for keeping them healthy. Sure you might get unlucky and get lot's of patients with very complicated problems but on average it would even out.

Again, I simplified it a lot and am no experts and there have been multiple health care reforms through the years, (actually 2004 is when the new system started) but that is the gist of it.

The health care system has extremely eroded over the years here in Germany. People wait months to see a specialist and life saving operations are postponed constantly. We are on the brink of collapse and that was before covid hit.

All because certain politician were sold on the idea that health care should be run like a business.

I think this depends on what the debtload of your area’s new dentists might be like.

Interesting point. For whatever it may be worth, I live in Canada, though I don't believe dental school here is especially less expensive than it is in (say) the US.

Yeah, this seems like questionably consistent advice, especially in this day and age of endless 'maximize your profit' courses. I'm sure there's plenty of things online on how to extract the most value out of your patients that any inexperienced dentist can use.

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