Accountability in Schools and Dentists

My dentist is better than your dentist, and I can prove it!

In a  seminar in Cheyenne, Wyoming, I made the statement that educational leaders have given up their leadership—that they have taken the politicians and business leaders’ approaches of accountability and competition as the models for learning. I should not have been shocked at the resounding applause I received from the 95 educators in the audience.

As I point out in the Epilogue of my book, both accountability as it is now used in high stakes testing—and competition—are counterproductive for learning. I quote the comic book character, Dagwood Bumstead, who said, “You know that makes a lot of sense if you don’t think about it.”

There is no doubt that competition improves PERFORMANCE, but competition is horrific for LEARNING. If you never stand in the winner’s circle, you would rather drop out than compete.

Similarly, no one with a good understanding of STANDARDIZED tests and an objective viewpoint can justify their use to rank teachers, schools, or school districts in any RELIABLE and VALID way.
Esther Williams of Opelika, Alabama, shared with me the following when we both presented at the Ives School in Lincolndale, New York, a facility for incarcerated youth.

Absolutely the Best Dentists by John Taylor, Superintendent of Schools, Lancaster School District, South Carolina

My dentist is great! He sends me reminders so I don’t forget checkups. He uses the latest techniques based on research. He never hurts me, and I’ve got all my teeth, so when I ran into him the other day, I was eager to see if he’d heard about the new state program. I knew he’d think it was great.

“Did you hear about the new state program to measure the effectiveness of dentists with their young patients?” I asked.

“No,” he said. He didn’t seem too thrilled. “How will they do that?”

“It’s quite simple,” I said. “They will just count the number of cavities each patient has at ages 10, 14, and 18 and average them to determine a dentist’s rating. Dentists will be rated as excellent, good, average, below average, and unsatisfactory. That way, parents will know which are the best dentists. It will also encourage the less effective dentists to get better,” I said. “Poor dentists who don’t improve could lose their license to practice.”

“That’s terrible,” he said.

“What? That’s not a good attitude,” I said. “Don’t you think we should try to improve children’s dental health in the state?”

“I sure do,” he said, “but that’s not a fair way to determine who is practicing good dentistry.”

“Why not?” I asked. “It makes perfect sense to me.”

“Well, it’s obvious,” he said. “Don’t you see that dentists don’t all work with the same clientele? So much depends on things we can’t control? For example,” he said, “I work in a rural area with a high percentage of patients from deprived homes, while some of my colleagues work in upper middle class neighborhoods. Many of the parents I work with don’t bring their children to see me until there is some kind of problem, and I don’t get to do much preventive work.”

“Also,” he said, “many of the parents I serve let their kids eat way too much candy from an early age, unlike more educated parents who understand the relationship between sugar and tooth decay. To top it all off,” he added, “so many of my clients have well water which is untreated and has no fluoride in it. Do you have any idea how much difference early use of fluoride can make?”

“It sounds like you’re making excuses,” I said. I couldn’t believe my dentist would be so defensive. He does a great job.

“I am not!” he said. “My best parents are as good as anyone’s, my work is as good as anyone’s, but my average cavity count is going to be higher than a lot of other dentists because I choose to work where I am needed most.”

“Don’t get touchy,” I said.

“Touchy?” he said. His face had turned red, and from the way he was clenching and unclenching his jaw, I was afraid he was going to damage his teeth. “Try furious. In a system like this, I will end up being rated average, below average, or worse. My more educated patients who see these ratings may believe this so-called rating actually is a measure of my ability and proficiency as a dentist. They may leave me, and I’ll be left with only the most needy patients. And my cavity average score will get even worse. On top of that, how will I attract good dental hygienists and other excellent dentists to my practice if it is labeled below average?”

“I think you are overreacting,” I said. “’Complaining, excuse making, and stonewalling won’t improve dental health.’ I am quoting from a leading member of the DOC,” I noted.

“What’s the DOC?” he asked.

“It’s the Dental Oversight Committee,” I said. “A group made up mostly of lay persons to make sure dentistry in this state gets improved.”

“Spare me,” he said. “I don’t believe this. Reasonable people won’t buy it,” he said hopefully.

The program sounded reasonable to me, so I asked, “How else would you measure good dentistry?”

“Come watch me work,” he said. “Observe my processes.”

“That’s too complicated and time consuming,” I said. “Cavities are the bottom line. It’s an absolute measure.”

“That’s what I’m afraid my patients and prospective patients will think. This can’t be happening,” he said despairingly.

“Now, now,” I said. “Don’t despair. The state will help you some.”

“How?” he asked.

“If you’re rated poorly, they’ll send a dentist who is rated excellent to help straighten you out,” I said brightly.

“You mean,” he said, “they’ll send a dentist with a wealthy clientele to show me how to work on severe juvenile dental problems with which I have probably had more experience? Big help.”

“There you go again,“ I said. “You aren’t acting professionally at all.”

“You don’t get it,” he said. “Doing this would be like grading schools and teachers on an average score on a test of children’s progress without regard to influences outside the school, the home, the community served, and stuff like that. Why should they do something so unfair to dentists? No one would ever think of doing that to schools.”

I just shook my head sadly, but he had brightened.

“I’m going to write my representative and senator,” he said. “I’ll use the school analogy. Surely, they’ll see the point.”

He walked off with that look of hope mixed with fear and suppressed anger that I see in the mirror so often lately.

The follow-up story:
Forget the Children – My Dentist Now Gets A Top Rating by John Taylor, Superintendent of Schools, Lancaster School District, South Carolina

My dentist bent over me in his usual no-nonsense manner.

“Open wide,” he said.

“Hold on a second,” I said.

It had been quite a while since I’d seen my dentist (despite his timely reminders).

“I couldn’t help but notice the rating posted in your waiting room. I thought you had a bunch of objections to rating dentists on the cavity counts of their young patients, but for someone who was so upset about the new state program for improving children’s dental health, you seem to have come out quite well,” I said smugly. “I told you that you had nothing to worry about.”

“One does what one has to do,” he responded somberly. “The cavity average of my young patients is now as good or better than that of dentists of my training and expertise across the state.”

“Aren’t you embarrassed about how you responded to the State Dental Improvement Program when I first brought it to your attention?” I said. “I knew you were a great dentist! I’ve noticed you have even improved the look of your office since my last visit. The waiting room is much neater.”

“That’s probably because fewer children are running around in there,” he said.

“Fewer children?” I said. “Why?”

“I’ve lost some of my patients because they and their parents wouldn’t do their part. I now require all my patients to see me every six months as long as they are progressing well. For patients with above the state average of cavities for their age, I require visits every three months. It’s working better than I feared,” he said. “I’ve only had to drop about 30-35% of my children for failure to meet my requirements. And the dental health of my remaining young patients is now really quite good,” he said.

“But what about the children you dropped?” I asked, horrified. “Where do they go for dental care? There aren’t other dentists in this area who serve that clientele.”

“I don’t know,” he said gravely.

“How can you do that?” I gasped. “Think of the children – you can’t just drop them. Besides, that’s like cheating. Your rating doesn’t mean anything.”

“Don’t go getting ‘holier-than-thou’ with me,” he said. “I’m the one who told you the ratings don’t mean anything. There are too many factors dentists can’t control. I have simply chosen to control the things I can control to preserve my reputation, and possibly my practice.”

“But…the chil-children,” I stammered.

“Look,” he said sternly. “If I lose my reputation, or, heaven forbid, even my license to practice, I won’t be helping any children—or you either.”

“But, the children,” I murmured again. “What happens to the ones who failed to meet your standards?”

“Look,” he said, “I don’t feel so great about that either. So, I do what I can. I do some pro bono work at the emergency room on really severe dental crises; they don’t count such work against my average. I’m doing the best I can under the circumstances.”

“But,” I said, “if this is happening all over the state, think of all the children who aren’t getting any dental care. Surely this is not what the law intended.”

“Listen, I’ve become quite an expert on what happens when you beat people up with numbers and ratings,” my dentist said. “Do you remember when I said no one would ever think of trying a program like this with schools?

“Well, I found out they have,” he continued. “In Texas and South Carolina and many other states around the country, schools are being rated with raw averages of student test scores, just like the Dental Improvement Program with cavity averages. And, in many schools, students who don’t meet standards within arbitrary time frames are failed. And many are dropping out.”

He glared at me and went on. “I just read an article about the large number of children who drop out of school in Texas. It should be a disgrace, but instead it drives up the averages, and Texas is being touted as a nation model for school reform. Need I say more?”

“Wow,” was all I could think of to say. I should have said, “Ugh.”

He was wound up now, and he did say more.

“W. Edwards Deming, the famous management expert often credited with Japan’s great economic turn-around after the war, said that when systems beat people up with numbers, averages, and quotas, the numbers invariably rise but are most often meaningless. Deming often said that the most important factors are not quantifiable—but, obviously, no one is paying attention to him.”

“This is a bad system,” I said. “I see it now. We need to change it. Averaging cavities is the wrong measure. We need to observe dentists in practice and account for differences in clientele. We need to assess and help people individually.”

“Too complicated and time consuming—to use your own words to me,” my dentist smirked. “Besides, cavities are an absolute measure, and you can’t argue with an absolute measure.”

“Now, open-wide,” he said, jerking my jaw down.

“Ughmmph,” I said.