Whether it is right to set a lower quality standard for certain groups than for everyone else, on the theory that substandard care is better than no care at all, is a first-class ethical dilemma.
I’m going to let you in on a little secret: some dentists are better than others. More experienced. More skillful. More compassionate. Better communicators, managers, diagnosticians and so on. But that license on the wall is the patient’s guarantee that the dentist has met at least the minimum standard of competence required to treat the people—all the people—of the state or province.
And while access to care remains a thorny and important issue, the basic, minimum, statutory quality of that care is something that the public assumes to be a basic attribute of a civilized community, like safe drinking water. A practice on the Upper East Side may differ in many respects from one in Lower East Overshoe, but there is comfort in knowing that both dentists graduated from accredited programs and passed the same exams to win their licenses.
Or such was the situation until September 2002, when the governor of California signed into law the Mexican Physician Pilot Program (Chapter 1157, Statutes of 2002). Introduced as A.B. 1045 by Assemblyman Marco Firebaugh, the law authorizes 30 physicians and 30 dentists to practice in California community health centers on the strength of their Mexican credentials. The premises of the bill, stated plainly enough in its language, are (1) that California’s large Latino patient population is not reflected in the ethnic composition of practitioners; (2) that the quality of care delivered to these patients suffers as a result; and (3) that Latino patients would benefit from a greater number of doctors whose "language, cultural traditions, and sensitivity" were more closely aligned to their own.
This is no shoddy piece of legislation. It includes a long catalog of requirements (credentials, courses and supervision) for dentists licensed outside the United States who wish to participate in the program. The nonrenewable permits to practice are limited to three years. A formal process to review the program’s success is written into the law. It might have been a great deal worse.
Now, I would not for a moment challenge the underlying problem that Mr. Firebaugh sought to address in his bill, nor the sincerity of his approach. In our practices, we soon learn that a linguistic or cultural mismatch can complicate, even compromise, the relationship between doctor and patient. Nor do I question the competence of the 30 dentists who will enter the program. They will all be graduates of a respected dental school, fully qualified for licensure in Mexico, and subject to an exceptional level of scrutiny both before and after they enter practice in California.
What does bother me, a lot, is the requirement that they practice only in certain nonprofit community health centers, with an emphasis on those in predominantly Latino communities. The law, however worthy its aims, thus firmly establishes a two-tiered system of credentials. That is bad enough in itself, but what makes it so troubling is the fact that the lower standard of care is reserved for certain (less affluent, non–English-speaking) patients. Is this really the direction in which we want to go?
Access to care figures prominently among the many health care problems facing America. It’s a real concern to dentistry. Most of us do our bit to help, in ways ranging from individual pro bono treatment to very ambitious statewide programs and, of course, the ADA’s annual Give Kids A Smile program. But the public is getting tired of hearing "we’re working on it," and is demanding more concrete action. Under such pressure, the legislatures’ traditional reluctance to interfere in professional licensure is giving way to more activist solutions. To the best of my knowledge, though, the California law is unique in singling out one patient group for special, diminished protection.
We are accustomed to looking to the boards of dental examiners as the final arbiters of professional quality. Don’t forget, though, that their powers are delegated to them by their respective legislatures, and can be abridged or bypassed via the political process. It’s our responsibility not only to educate elected officials about the complexities of dentistry, but also to work with them to develop workable solutions that are truly in the public interest.
Whether it is right to set a lower quality standard for certain groups than for everyone else, on the theory that substandard care is better than no care at all, is a first-class ethical dilemma. You may reach a different conclusion than I. Just don’t forget that "the public" is composed of individual people needing care, not mere socioeconomic categories.
