The issue of access to dental care today looms larger on the political screen than at any time in the recent past. National efforts to improve access have focused on children (CHIP being the most recent effort), with attention to the elderly—particularly those in nursing homes—and other patients with special needs.
At the same time, the issue of competency has received attention in discussions of dental curricula and licensing. Access and competency are being discussed in different arenas. I propose that these two issues would increasingly overlap with improved access, and that dealing with one issue will become difficult without dealing with the other.
As a dean struggling to define and assess entry-level competency in our graduates, I am concerned about the current view of competency and suggest that a discussion is in order on the interface of access and competency.
While the current emphasis on competency correctly requires capacity to perform common procedures, I wonder how much it should include ability to provide care for large segments of the population. As access to care improves, will today’s dental graduates and best general dentists be able to treat patients with increased access?
The reasons for my concern are both simple and complex. My case is based on the assumption that patients with less access to dental care have become more difficult to treat in the last 25 years or so. The level of competency needed to treat these patients has risen and may continue to rise due to behavioral, medical and technical challenges.
Let me offer two examples—one focusing on children, the other on the elderly.
Children with limited access to care have more disease than those with greater access. A 3-year-old with access to an early preventive program and regular care is more likely to be within the competency range of an average dental graduate or experienced general dentist than a child with bottle caries or early childhood caries.
A valid concern has been raised that dental graduates could have more experience performing some procedures for children—for example, stainless steel crowns. I have a greater concern in managing the child and the conditions underlying the need for multiple stainless steel crowns.
Likewise, today’s elderly are living longer and keeping more of their teeth. But with these longer life spans, we see more Americans in nursing homes and more who are taking multiple medications or confronting problems like dementia.
Today’s dental graduates and experienced general dentists are competent to treat relatively healthy, independent older adults. But are they prepared to meet the needs of those living in nursing homes and dealing with chronic health problems?
As a profession, I suggest that we need to establish a reference point for competency. Should it be the dental graduate? Should it be the outstanding general practitioner? I suspect that even many of our best general dentists would find it difficult to manage some of the examples above.
Should we expect today’s graduates to be competent in managing patients whom many dentists are uncomfortable treating or unable to accommodate in their practices?
Some may argue that specialists should assume care for our more difficult patient cases. If so, success in addressing access issues will mean that dentists with postdoctoral training must assume disproportionate responsibility for new cohorts of patients.
I submit that the time is right to combine our discussions of access and competency. Organized dentistry is the best place for these coordinated discussions to begin.
