Access to Care: Something to Think About
Dr. Michael Kolodychak
Access to care. It’s the new “buzz phrase” in dentistry. If you are not familiar with the buzz…be aware, you will be. Access to care is an issue that has become a bigger concern in our profession over the last few years as community water fluoridation has appropriately been encouraged to improve the oral health of those in “underserved and underprivileged areas.” The provision of dental care in Alaska, as well as the alleged lack of dental health care providers in this state has been debated on the local, state and the national level. Most recently, the suggested lack of “access to care” has been the motivation for dental hygienists to lobby Washington, D.C. for an entirely new profession…the Advanced Dental Hygiene Practitioner (ADHP)…all on the premise that the ADHP will improve the availability of care to the underprivileged.
So as a dental student relatively new to the profession of dentistry, how much do you know about this debate? What does it mean to you? Why should you care? After all, as a student trying to just make it through dental school, you probably don’t perceive an issue in regard to access to care. Most of us in private practice have believed at one time or another that we could “always be busier – surely there can’t be an issue with access.” My suggestion: pay attention, because this issue of alleged limited access to care has the ability to change the future of our profession perhaps more than any other issue recently debated.
Before you read on, I should tell you that this brief article gives a little insight into my perception of the situation, which seems to be misunderstood by the hygienists. My thoughts as articulated below are not representative of the views of the Pennsylvania Dental Association. This article does not attempt to provide definitive answers. As a private practice oral and maxillofacial surgeon, I would humbly suggest that I do not have all of the answers. Nonetheless, my background in public health and my experience in practicing my profession in a successful, growing practice for many years now has given me confidence that my views are consistent with the views of many of my constituents. I am hopeful that these random ideas are thought provoking and that they motivate you to want to learn more.
Earlier in 2006, an attractive, colorful brochure came to my attention. The brochure encouraged dental hygienists to lobby Congress on their “day on the hill” (March 21, 2006) for the establishment of the ADHP profession. Surprisingly, this brochure had suggested that the ADHP “will provide diagnostic, preventive, restorative and therapeutic services to patients. Services could include: local anesthesia administration, nitrous oxide administration, matrix/wedge removal, cavities preparation, emergency treatment; placement, contouring and adjustment of amalgam and composite restorations, ART (atraumatic restorative therapy), and simple extractions.” (And to think that it was only a year ago when I was being told that the administration of local anesthesia by hygienists WAS GOING TO FIX THE ACCESS PROBLEM!)
In the May/June issue of Access Magazine the official publication of the American Dental Hygienists’ Association, Jeff Mitchell stated that “the clear agenda for the day was to influence legislators to write the Health Resources and Services Administration (HRSA) in support of exploration of the Advanced Dental Hygiene Practitioner (ADHP) – a new oral health care provider who will address access to health care.” The suggestion that a new profession is needed to address these concerns is essentially a condemnation of dentistry’s ability to assess and treat a problem that dentistry was founded to manage in the first place.
The assertion that hygienists should fulfill this role is concerning to me for numerous reasons. First and foremost, I believe that it is our ethical responsibility as dentists to monitor, police, and improve the manner in which we provide care to patients…not the responsibility of hygienists. This includes tracking and assessing shortcomings of our efforts to provide care to the public. Although there is no doubt in my mind that rural areas are lacking a significant number of well-qualified dentists to provide care to patients, I am not confident that a whole new health care model is the solution. In fact, I cannot morally accept the thought that a lesser-trained, lesser-qualified provider is an acceptable alternative.
I am proud of the fact that the “trade” of dentistry established centuries ago has given way to the “profession” of dentistry. There has been a greater emphasis in the required educational curricula to teach general pathology and medicine, which mandates a broad, basic knowledge of the natural sciences…a process that essentially requires at least seven or eight years of formal education. As professionals who went into our profession to maintain and improve the oral health of those in our communities, we must ask ourselves if the establishment of the ADHP will, in fact, be in the best interest of the public.
At best, the recommendation of the ADHP position is a not-so-subtle suggestion on the part of dental hygienists that something must be done by the dental community to assist those individuals who are in need of better access to dental care. Unfortunately, this recommendation reeks of self-servitude. If dental hygienists were concerned about accessibility to dental care, these same hygienists would be lobbying for special consideration for admission to dental school so that they might receive a Doctor of Dental Medicine (DMD) degree, or a Doctor of Dental Surgery (DDS) degree. My suspicion is that if these hygienists had any idea about what our curricula consisted of in order for us to earn our degrees (as well as the privilege to provide dental care to patients), they would understand how inappropriate their request is to create this new ADHP position. How would the hygienists feel if Expanded Function Dental Assistants (EFDAs) started lobbying for privileges to clean teeth? It would have been refreshing for the hygienists to approach organized dentistry to ask how the hygienists could help us to do what we are here to do. Unfortunately, it appears as if the ADHP proposal is just another backdoor approach to hygienists achieving independent practice.
I know what some of you are saying; the ADHP will practice under the supervision of a general dentist and therefore will enable the dentist to perform more complicated procedures and techniques. Our profession cannot tolerate gullible thinking like this. Remember when dental hygienists wanted to administer local anesthesia to improve access to care? Some of us made the mistake of believing this underhanded calculated political maneuver, believing that hygienists could help our practices by improving patient flow through the administration of anesthesia. It was only about a year ago that the privilege to administer local anesthesia was the only privilege that the dental hygienists wanted. Now it appears that they want to be dentists!
(*Editor’s Note: Allowing dental hygienists to administer local anesthesia remains just a proposal in Pennsylvania at this stage and is not a done deal. The State Board introduced regulations to allow this but they have not been finalized. The ultimate outcome is uncertain.)
If we leave the decision of who should provide these various services to the government, the health of the public could quite possibly be compromised; we owe the public more than this! It might seem unlikely to some of you that our government would make a decision that would not be in the best health interest of the general public. One doesn’t have to look very hard to find an example that proves the legitimacy of this concern. Remember the repeal of the helmet laws for those who ride motorcycles? Ask any of your local emergency room physicians if they believe this was in the best interest of the public. Not to sound like a cynic, but politicians will do what will get them re-elected…they don’t necessarily always do the “right” thing.
As I continue to contemplate these issues, I can’t help but ask the following questions:
- Who said that there is an access to care problem in this state?
- What efforts were made to communicate this problem to dentists?
- What role did dentists play in assessing the access problem?
- Why would the dental hygienists believe that they should perform the same services provided by dentists in order to address an alleged access problem?
- Why do those hygienists lobbying Washington, D.C. believe that a new position will fix the problem?
Obviously these questions can go on and on.
As clinicians, we are taught in school that in order to offer the correct treatment for the management of a disease, we must first diagnose the disease properly. The creation of an ADHP does not address the problem of why there is limited access to dental care in rural communities, and this is perhaps the most important reality that those on the hill must remember when consideration is given to reconstruct our existing health care model.
The creation of an ADHP profession does not directly address the problem of access to care, but instead it adds a whole new “echelon” of dental care provider, which will ultimately have the same issues that dentists now face. In fact, I propose that it will introduce several new problems. For example, if the ADHP program is to be established to provide care to rural areas, who will determine which areas are underserved? What magic formula will be used to define an underserved or underprivileged area? What will happen if an ADHP would like to go into an established community, which already has a number of dentists to serve the community – how will this improve access to care? How will the general dentists in that community (some of whom might support the ADHP position) feel about competing with a dental hygienist to provide basic dental care?
So with these questions being raised, you’re wondering, “what is the answer?” It would be inappropriate for me to make the solution sound easy, because after all, it is not. Nonetheless, although the solution is not easy to implement, it is somewhat obvious.
The assertion is that there is a shortage of dentists. Since our dental schools have record numbers of applicants, and since we as a state have “limited access to care,” does it not make more sense that we find a way to graduate more dentists, with the requirement that some of these dental student positions be created for the establishment of a “community health dentist?” The community health dentist would be an appropriately trained dentist who will provide a traditional scope of practice to patients in need. The ADHP would not be able to offer the full scope of these services, hence there would still be a limitation in “access to care” if the ADHP were the alternative. Preferably, the community health dentist applicant should be from these underserved areas, as this individual will probably be able to better serve the public through his or her familiarity with local political and business issues.
As a dental student or a recently graduated dentist, what can you do? First of all, ask questions. Talk to the senior dentists in your community. Attend a local dental society meeting so that you are well informed. Find some way to volunteer a little of your time. If we all do a little…it will make a difference. Look for opportunities to help at free clinics, travel to assist with hurricane relief, maybe take calls at local hospitals. Speak with faculty members and deans at dental schools about issues related to access to care. LEARN AND DEVELOP YOUR POLITICAL VOICE. Become involved in the process. As individuals who pursued a dream to provide health care to a public who needs it, we should not resent the hygienists’ pursuit of the ADHP position. Instead, we should embrace this as an opportunity to grow as a profession.
In summary, this issue is HUGE! Our ethics mandates that we not be apathetic about the health of the public. Lack of new dentist participation in this situation will result in an eventual conversion of doctors providing dental care to patients to doctors supervising numerous dental hygiene practitioners who are providing this same care. Is this in the best interest of the public? For those of you who might be reluctant to get involved in organized dentistry for lack of a true purpose, the purpose is here and the time is now. Whether you agree with me or not, I am hoping that I gave you “something to think about.”