Can business incentives and business ethics ever coexist in true harmony?

I FIRST LEARNED about business incentives as a teenager working in my dad’s shoe store. A wonderful employee named Fern was amazing at getting “spiffs”: little bonuses for selling customers cans of shoe polish or other add-on goods.

I marveled at Fern’s ability to up-sell for emoluments, but soon came to realize that she was sometimes . . . a little pushy. She’d warn customers of imminent danger to their footwear if they failed to buy polish or protectant, to the point of making them visibly anxious. I learned how to stir people’s emotions by study-ing her techniques — yet something inside me felt funny when I watched people make purchases on this basis.

The same kind of situation occurs in dental practices, too. A dentist can pay her team one of several ways: a straight salary, via commission or some hybrid of the two. In my consultancy, I often see bonuses or spiffs paid to staff for selling elective products — whitening kits or brushes — to patients.

Fee collection is another example. Say a front-office team member gets a bonus for reaching the monthly collection rate of 95 percent. This seems like a good reward system, and it’s even better if collections get to 100 percent, right? Most consultants, though, would regard a perfect rate as a potential problem. Is the office too aggressive in pursuing payment, and thereby alienating some patients?

Front-office staff might also be uncomfortable with some of the tactics espoused by a dentist who indeed wants to pursue collections with urgency.

They’ll experience that same discomfiting sensation I felt all those years ago in Fern’s presence — the whole thing just seems a little unethical.

I worry that health-care professionals who are heavily incentivized with pay strategies and bonus systems risk losing sight of their patients’ best interests. Teams focus on grabbing that brass ring, and they begin to manipulate their schedules and services to ensure their financial goals are met before their patients’ needs are. (This dilemma was at the heart of the major recent scandal concerning Wells-Fargo’s consumer banking services.)

As more and more data become available to measure patient interactions, the temptation to meet a goal or earn an incentive — versus meeting patients’ needs first and foremost — will be even more seductive. Of course most professionals can remain ethical when faced with an assortment of alluring options, but if dental teams don’t discuss these potential pitfalls now, many practices will learn them the hard way: by losing patients. Too many such stories will put at risk dentistry’s hard-won reputation as a respected, trustworthy profession.

Look carefully at how you incentivize your team. Make sure each of them reflects the ethical standard to which you hold yourself. If you want to implement a bonus system, be sure you know why you wish to do so. If you put one in place, make certain that it’s having the desired effect and isn’t derailing your best intentions. In a perfect world, business ethics and business incentives would coexist without friction. However, in the actual world you and I — and, bless her heart, Fern — inhabit, that’s not always the case. Be sure you stay on the right side of the dividing line.

DR. LISA KNOWLES is a practicing dentist in Michigan. She founded IntentionalDental Consulting to help dentists have more peace in their practices. You can find her blog and speaking topics at