COURSE GOAL:
SOCI57H is an honors seminar taught by Professor Aldrich at the University of North Carolina, Chapel Hill. This course is dedicated to understanding McDonaldization, a theory coined by George Ritzer in his 10th Edition McDonaldization of Society: Into the Digital Age that characterizes and explains rationalized changes to today's businesses. Class discussions and activities expose students to the manifestation of Ritzer’s theory in various industries: medical, education, legal, and sport. Throughout the term, students are tasked with identifying Ritzer’s established trends in their own selected profession. This website serves as a sample of my semester-long research project on how the field of dental hygiene has experienced Ritzer's rationalization over time.
WHAT IS MCDONALDIZATION?
McDonaldization is a specific form of rationalization: the evolved methods of operation that produce more efficent, calcuable, predictabled, and controlled practices than what pre-existed. Specifically, McDonaldization refers to the pursuit of those four mentioned characteristics in the fast food industry, a progression that is being replicated in other industries (Ritzer, 2021).
"McDonaldization is the process by which the principles of the fast-food restaurant are coming to dominate more and more sectors of American society as well as of the rest of the world." - Geroge Ritzer
THE FOUR DIMENSIONS:
EFFICIENCY: an operating method based on speed that works by finding the optimum method for getting from one point to another.
CALCULABILITY: an operating method based on the quantification of production with an emphasis on numerical outputs.
PREDICTABILITY: a standardized and uniform operation in which the customer knows what to expect.
CONTROL: an operating method that makes use of non-human technology and structural constraints to limit the autonomy of customers and place decisions in the hands of the company.
In pursuit of the previous four standards, the field of dental hygiene has come to mirror Ritzer’s McDonald's model.
WHAT IS DENTAL HYGIENE?
The American Dental Hygienists Association (2023) defines dental hygiene, the domain of dental hygienists, as actively "assisting individuals and groups to achieve and maintain optimal oral health." This essential healthcare role, born from the proven benefits of preventive care (prophylaxis), involves plaque removal, X-rays, fluoride application, and patient education.
As the field embraces rationalization, its tools, standards, work environments, and educational requirements are undergoing rapid evolution. While historical resistance and occasional setbacks exist, the steady advancement of dental hygiene remains undeniable.
THE ORIGINS OF DENTAL HYGIENE:
In the early 19th-century, dentistry shifted from fixing oral problems as they arose (reactive) to preventing them (proactive). Brushing and flossing gained popularity, reflecting this new focus. Seeing an opportunity for efficiency, dental professionals called for an "auxillary" role to dentists that would provide early oral health maintenance as preventative care (New York Tuberculosis and Health Association 62).
This divergence, specialization in the dental field, reflects a common approach to rationalization, Taylorism: breaking each job down into its individual motions to perfect each one. By leaving cleaning duties to hygienists, dentists could focus on perfecting their distinguished responsibilities, drastically increasing the speed at which work could be performed. Additionally, much like an assembly line, the dentist could work on one patient while the hygienist cleaned another (Britannica, 2024).
1900 TO 1950: THE ERA OF EDUCATION
In the early 20th century, educational advancements were key to the field of dental hygiene, reaching every sector of the industry. Individual practitioners saw the new opportunity to train at a formal school while patients, newly molded prosumers, spent a significant portion of their appointments being educated by a hygienist about oral care.
EDUCATION: Before standardized programs emerged, dental hygiene education lacked uniformity. Apprenticeships and assistantships were the primary training methods (O’Hehir, 2018). However, by 1945, a shift occurred. Sixteen official dental hygiene programs existed, but they varied considerably in program length, educational level, prerequisites, and resulting certifications (O’Hehir, 2018).
ASSOCIATIONS: The American Dental Hygiene Association (ADHA), established in 1923, significantly standardized dental hygiene education to address the variation. The ADHA implemented a 2-year accreditation standard and required specific educational disciplines, interprofessional collaboration, and uniform student admission criteria for institutions (Commission on Dental Accreditation, 2023). The ADHA's initiatives resulted in the production of similarly trained practitioners, who shared a foundational knowledge, ensuring the consistency and predictability of dental services across various locations and times, aligning with Ritzer’s concept of rationalized predictability in services.
PROSUMERISM: Dental hygienists have evolved into educators since the early 1900s, initially teaching oral hygiene in schools and later incorporating it into patient appointments. This educational role aligns with Ritzer's concept of prosumerism, where patients act as working consumers by engaging in self-service oral care, like brushing and flossing, which indirectly assists hygienists by reducing plaque buildup and simplifying cleaning procedures.
1950 TO 1980: THE ERA OF EXPANSION - MORE PEOPLE INVOLVED
While hygienist duties expanded in the early 20th century to include patient education and higher education requirements, the profession remained predominantly homogenous until the latter half of the 1900s, when it diversified to include men, different races, and other medical professionals.
DEMOGRAPHIC CHANGE: In the early 20th century, the field of dental hygiene in the United States was exclusively composed of women and was racially segregated, with the ADHA imposing membership restrictions based on race, creed, and color until 1957 (Sindecuse Museum of Dentistry). That year, discriminatory practices were abolished, and by 2022, the ADHA had publicly committed to diversity and inclusion. The profession also shifted from being exclusively female when the ADHA removed the word "female" from its Constitution in 1964, admitting the first male hygienist in 1965 (Sindecuse Museum of Dentistry). Broadening diversity in industries, including dental hygiene, has been shown to improve not only the richness of the talent pool but also operational efficiency, sales revenue, customer base, market share, and profitability, thus enhancing overall industry rationalization and success (Diaz et al., 2021).
EHRs: Electronic Health Records (EHRs) revolutionized dental hygiene in the mid-20th century by replacing traditional paper charts, thus enhancing communication among dentists, hygienists, and other health professionals. This improved collaboration allowed dental hygienists to expand their networks, including specialists and various clinics, and facilitated more efficient processes by standardizing data, reducing errors, and eliminating the need for physical storage of records (Menachemi & Collum, 2011).
1980 TO 2000: THE FIGHT FOR AUTONOMY
In the 1980s, dental hygienists sought more autonomy, challenging the rationalized system where they were seen as parts in a patient care "assembly line." While working alongside dentists offered efficiency, hygienists felt their own expertise and decision-making were stifled by dentist oversight. This fight for autonomy reflected a pushback against the rigid control of their careers.
INDEPENDENT PRACTICE: Demonstration projects alike established programs to train hygienists in running businesses and trial-ran independent practices to collect data on patients, referrals, and quality of care that would support their cause (Martin & Mertz, 2010). With this movement, progress ensued. Over the past 12 decades, the autonomy of dental hygienists has significantly increased. In 2000, 9 states allowed hygienists direct access (ability to treat patients without approval). But, by 2023, 42 granted permission (American Dental Hygenists Association, 2023)
Dental hygienist autonomy stands in opposition to the principles of rationalization. In a perfectly standardized system, hygienists would have minimal decision-making power. However, by 2000, hygienists had gained more control over their work, increasing their autonomy and moving away from the rigid, standardized model.
UNIFORMS: In the early 20th century, dental hygienist uniforms were impractical, consisting of stiff white dresses and caps that restricted movement. By 1971, changes allowed for pants to facilitate better movement and comfort. Modern uniforms evolved into smock-like cotton attire, better suited to a fast-paced work environment.
2000 TO 2020: CORPORATE TAKE-OVER
Enduring a successful (and still ongoing) fight for autonomy in the 1980s through 90s, hygienists in the 2000s felt rationalization’s counterpull. In their constant tug-of-war, rationalization responded to the previous era with corporations and overseeing bodies.
DSOs: Dental Support Organizations (DSOs) manage the business side of dental practices, aiding in the industry's corporatization and promoting standardization across practices (Garvin, 2022). Popular since the 2000s due to rising student debt (inability to open private practices), DSOs handle functions like scheduling, HR, and billing, thus reducing dental hygienists' autonomy and centralizing control under corporate management. They also integrate advanced technologies to outperform independent clinics, ensuring uniformity in service delivery. According to Ritzer’s model, DSOs enhance the calculability and predictability of dental services through professional management and advanced systems, further standardizing practices (Ritzer, 2021).
ALLIANCE CODES: The Dental Quality Alliance (DQA), initiated by the American Dental Association, was established in 2008 to oversee industry standards. Aiming to enhance oral health and safety, the alliance develops performance measurements for all dental practitioners, from independents to large corporations, effectively standardizing care practices (Dental Quality Alliance, 2022). The DQA has implemented standardized benchmarks such as the PEV-A-A, DOE-A-A, and EDV-A-A codes that suggest certain metrics practices should achieve and require practices to report, using the values of these codes, the quality of their service.
2020: THE PANDEMIC STRIKES
The COVID-19 pandemic, “the ultimate in irrationality” according to Ritzer, was an exception to the perpetuation of rationalization in the dental field (Ritzer, 2021).
COVID-19 disrupted the efficiency of dental hygiene. Fear of infection due to close contact and tools made appointments stressful. Both patients and hygienists worried about spreading the virus, leading to a shift away from streamlined procedures and a focus on safety measures that slowed things down.
OPERATION SLOWED:
Stringent measures like temperature checks, limited appointments, and extra cleaning reduced the number of patients hygienists could see daily, decreasing overall system calculability. Additionally, to minimize aerosol generation, hygienists switched from using ultrasonic scalers and air polishers to traditional handheld tools, which extended the duration of each appointment and decreased operational efficiency. Many patients even skipped appointments altogether, causing a dramatic drop in visits. In turn, after reopening, appointments remained longer due to the backlog of neglected oral care. In short, the pandemic response prioritized safety over efficiency, causing a significant slowdown in rationalization (Schoch, 2021).
OPERATION VARIED:
COVID-19 disrupted the standardization of dental hygiene. Safety protocols varied wildly between offices, with some closing entirely. Staffing also became less consistent as hygienists left the field and doctors used different PPE. Patients could no longer expect a routine experience, as offices might be closed or their hygienist gone. In short, the pandemic caused a breakdown in the uniformity that once characterized dental hygiene.
The COVID-19 pandemic challenged the idea that efficiency in healthcare always increases. Dental hygienists willingly sacrificed efficiency, predictability, and standardization to prioritize patient and their own safety during this time. This highlights a potential limit to the concept of "McDonaldization" - when safety is paramount, even highly efficient systems may need to adapt.
IRRATIONALITIES:
Ritzer, in "Rationalization in the Modern World," echoes Dylan Thomas's urging to "rage, rage against the dying of the light," which he equates to the process of rationalization. He warns that without resistance, the irrationalities and negative impacts of highly rationalized systems will escalate (Ritzer, 2021).
ENVIRONMENTAL DEGRADATION:
Rationalized dental offices, similar to fast-food chains like McDonald’s, contribute significantly to environmental degradation, a fact often overlooked given their primary aim to benefit human health. These practices are resource-intensive, consuming vast amounts of energy and water, and generate considerable waste, including 680 million disposable items like chair barriers and patient bibs annually (Vogell & Marleen, 2020). Additionally, the dental industry contributes to toxic waste with approximately 28 million liters of x-ray fixer and 3.7 tons of mercury released each year (Vogell & Marleen, 2020). The environmental footprint of these offices has surged over the past decade, exacerbated by the increasing demand for raw materials needed for dental technology and operations.
DEHUMANIZATION:
The corporatization of dentistry, which prioritizes efficiency and targets, significantly dehumanizes the field, detracting from the quality of worker interactions and patient care. This environment leads to high employee turnover and job dissatisfaction, driven by productivity-based compensation and reduced base salaries that put immense pressure on dental hygienists (Candell & Engstrom, 2010). Such settings not only stress the hygienists due to rushed appointments but also weaken the crucial patient-hygienist relationships that are known to be professionally stimulating. Furthermore, frequent changes in personnel hinder the development of positive workplace relationships and mentorship opportunities, contributing to a cycle of stress and dissatisfaction among dental hygienists within these corporate frameworks.
THE FUTURE
The future of dental hygiene, shaped by both efficiency gains and unintended consequences from rationalization, remains unclear. While Ritzer fears a bleak future, other see the potential for hygienists to better serve diverse patients. Predicting the path is further complicated by human biases and interconnected systems. We underestimate how long changes take and struggle to predict the complex ripple effects when one system rationalizes.
GIG WORK:
The future of dental hygiene seems to be headed towards gig work. EHRs eliminate the need for hygienists to have long-term patient knowledge, making them ideal for on-demand work. Finally, the high staff turnover in hygenist positions and the job shortage caused by COVID-19 create a perfect environment for adopting a more flexible work model. Apps like CloudDentistry already exist to connect hygienists with open positions, showcasing the potential of this gig-based future (CouldDentistry, 2024).
AI:
AI: Artificial intelligence (AI) is poised to significantly impact dental hygiene. AI excels at analyzing data and images, potentially improving scheduling and diagnosis accuracy. Researchers believe AI will act as a collaborator, not a replacement, for hygienists. A recent study even showed AI achieving higher scores than doctors in core clinical reasoning areas, highlighting AI's potential to enhance hygienists' skills for better patient care (Cabral et al., 2024).
STATISTICAL OUTLOOK:
The job outlook for dental hygienists remains strong despite concerns. The US Bureau of Labor Statistics predicts a 7% growth by 2032 due to an aging population keeping their teeth 2032 (U.S. Bureau of Labor Statistics, 2023). Additionally, the field offers diverse options. Independent practices allow more autonomy, while corporate jobs provide structure and support. Studies show hygienists value both options, making the field attractive to a wider range of professionals.
A FINAL NOTE:
Rationalization has significantly improved the field of dental hygiene by enhancing education, standardizing care, and increasing efficiency, which allows professionals to treat more patients and achieve higher profits. Despite these advancements, the field is continuously adapting to find the most productive ways to navigate modern challenges, such as those posed by the COVID-19 pandemic and hygienists' fight for autonomy, which have slowed some aspects of rationalization. However, Ritzer warns of growing irrationalities such as threats to humanity, environmental impacts, and workforce retention that accompany these benefits of rationalization. As the field evolves, those entering the workforce are urged to weigh the benefits of increased efficiency and profit against the potential harms of dehumanization and environmental degradation, and to consider whether their contributions to rationalization ultimately do more harm than good.
REFERENCES:
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FULL TERM PAPER ACCESS:
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DISCLAIMER:
*Gemini & ChatGPT4 were used to summarize term paper information. All original paper content is my personal intellectual property. Responses were slightly modified to enhance summaries with critical informal AI had excluded.*