THE REPOSITIONING OF PARAMEDICAL PROFESSIONALS

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What is so unfortunate both for the dental profession and for patients is that while paramedical professionals—such as optometrists who now can become "optometric physicians," podiatrists/chiropodists who now are called "podiatric physicians," and chiropractors who can call themselves "chiropractic physicians" in some states without any training for invasive procedures (and with no prescription privileges)—have upgraded their titles, the dentist has retained the title of "dentist" that evolved from the "barber surgeon" of the 13th century through various combinations of "surgeon" and "dentist" until Pierre Fauchard became the first real "dentist" in 1728.¹⁹

The irony of the present situation is that, with the possible exception of podiatrists, other paramedical groups with less medical training than dentists have now can legally call themselves "physicians." Only dentists and podiatrists, however, are eligible for hospital admitting privileges and relatively unlimited drug-prescribing authorization. It should be noted, however, that in 2004 "all 50 states plus [the District of Columbia] grant prescriptive authority in some form to advanced nurse practitioners, physicians’ assistants and optometrists. Pharmacists in many states can prescribe under certain protocols" (R. Jennings, prescription privileges coordinator, Legal and Regulatory Affairs Office, American Psychological Association Practice Directorate, written communication, February 2004). Some states also permit limited prescription and admitting privileges for optometrists. The term "chiropractic physician" is legal in 29 states,²⁰ and "optometric physician" is allowed in nine states (S. Cooper, B.A., oral communication, April 2002 and February 2004). The term "podiatric physician," né "chiropodist/podiatrist," now is legal in the majority of states (P. Coleman, D.P.M., oral communication, July 2002). A major factor in the motivation of the legislators to allow these other paramedical professionals to change their names was based on the need to be specific about which professions could use the term "physician." Another reason was to prevent naturopaths from calling themselves "physicians" without having appropriate health care training.²¹

Adding the word "physician" to the name of these other paramedical professions did not result in any great debate or public outcry. Whatever changes evolved in the educational curricula of these professions as a result of the name change were in response to the expansion of the scope of practice; that is, they did not wait until a new and better-educated breed of practitioner came along to change their titles. Similarly to dentists, these paramedical professions continuously revise their curricula for training of future practitioners. These changes arose in response to changes in knowledge and scope of practice, not to a name change²² (P. Coleman, D.P.M., oral communication, March 2002; D. Heath, O.D., Ed.M., oral communication, July 2002). The impetus for change to "optometric physician," "podiatric physician" or "chiropractic physician"—while possibly holding some relationship to motivation to enter the profession—has been essentially political. These professions simply took advantage of the health care access disparity problem and the relative permissiveness of some state and local medical and hospital associations as well as health maintenance organizations, Medicaid and other third-party payers in allowing chiropractors, dentists, psychologists, podiatrists and optometrists to be classified as physicians for compensation purposes.²³ In an apparent retreat to realism, however, some chiropractors actually feel uncomfortable about using the term "chiropractic physician" because of the chance of misleading the public about what they do.²⁴ Other chiropractors actually consider themselves as primary care physicians,²⁵ particularly in under-served areas.²⁶ There is in fact an American Board of Chiropractic Internists.²⁷

	BECOMING ‘ORAL PHYSICIANS’

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While Nash,²⁸ Goldhaber,²⁹ Bertolami³⁰ and Donoff³¹ wrote of the oral physician of the future, a term that Gies³² suggested in a 1926 report, the requirements of additional medical training and other curricular revisions proposed by these authors will take decades to accomplish. I propose that with some minor tune ups, such as taking continuing education courses, dentists certainly are as much physicians as are the other currently designated paramedical professionals and should be recognized as such. The designation "dental surgeon," a doctor of dental surgery, was and is an ironic compromise, given that surgery—except possibly oral and maxillofacial surgery—continues to be the province of medicine.

As Goldhaber²⁹ recognized, the debate on how much medical training is appropriate for present and future roles continues worldwide. Mason³³ summarized the situation as follows:

The role of the dentist is therefore changing and might more accurately be described as becoming that of an oral physician with highly developed skills involving manual dexterity who takes responsibility for all diseases affecting a particular area of the human body, in the awareness of the general health of the individual patient. In this way the dentist, whilst retaining a distinctive identity, is practicing in a similar way to an ophthalmologist, otorhinolaryngologist or dermatologist.^33p2

Mason also wrote that a common curriculum for all health professionals would facilitate greater cooperation among health professionals. This statement actually raises a perennial question: do practitioners in these subspecialties of medicine actually need the full medical school curriculum any more than do dentists to practice what they actually do? For example, the opthalmologist spends most of his or her time treating cataracts, disorders of refraction or glaucoma.³⁴ Similar observations about routine cases have been made for most medical specialties.

It is time to stop wishing and posturing. An enlargement of the medical pedestal to permit present and future oral physicians to stand alongside their general-physician colleagues will provide more incentive for the public to use dental practitioners to address an expanding list of health care needs that dental health professionals can recognize and meet effectively. Obviously, the subspecialties will be able to add the appropriate adjective—"endodontic," "prosthodontic," "periodontic" and so forth—to the basic term "oral physician." And also obvious is the fact that there still will be some dentists who will feel more comfortable pursuing conventional drill-and-fill activities. Other objections among dentists to changing the term "dentist" to "oral physician" include satisfaction with their designation and current responsibilities as dentists, indifference to change, self-perceived or actual lack of training and, most importantly, economic reasons such as lack of reimbursement for other-than-traditional dental problems and higher malpractice premiums. Rather than expanding their roles and, ultimately, status in areas that at the very least could be considered primary care functions, they prefer the status quo. As Donoff noted, this mind-set of continuing to function as an expert of "mechanical procedures rather than health care provider of dental medicine constricts the capacity for reflection and action."^35(p24–S)

On the basis of the surveys noted earlier of both dental health professionals and potential patients,^1–3 dental health professionals should start legislative lobbying efforts immediately to change the name of "dentist" to "dental physician" or "oral physician," on the basis of dentists’ current qualifications. Obviously, as with any profession, the curricula of predoctoral, postdoctoral and continuing education programs for oral physicians will continue to be updated to help clinicians adapt to changing health care needs.³⁶ As indicated by Donoff,³⁵ in the long term, "efforts will be needed to change the behavior of practicing new dentists for them to assume a new role as the doctor of the mouth. Such a role requires an attitudinal change from a limiting to an unlimiting behavior, which includes greater participation in the care of the whole patient and in larger systems of health care."^35(p20–S)

A general practice residency may be desirable to provide these new "oral physicians" with more hospital experience. These efforts also must be coupled with a major public educational program to ensure awareness of the fact that the dentist truly is a well-trained and highly skilled health professional worthy of the title "physician," certainly more so than the paramedical personnel cited above. Some progress already is evident, as demonstrated in the 2003 CNN/USA Today/Gallup poll, which placed dentists ahead of police, clergy, bankers and lawyers in terms of honesty and ethical standards.¹³

	SUMMARY

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In summary, a new designation for the dental profession is warranted, not because paramedical professionals have done it, but because the new designation is appropriate for what they are able to do. Moreover, it can be done now with little resistance or fanfare. As has been suggested by others, changing the name "dentist" to the name "oral physician" would result in several benefits:

– dentists’ being recognized as providers of services such as tobacco-use cessation, oral cancer screenings, nutritional counseling and, most recently, as a major health care resource for dealing with bioterrorism;

– the public’s visiting dental professionals for services other than traditional dental procedures;

– the profession’s being more likely to teach and provide services outside of traditional dental procedures;

– third-party payers’ being more likely to pay for services other than traditional dental procedures;

– the improvement in the public’s oral health that would result from patients’ visiting "oral physicians" for services other than traditional dental procedures.

	THE EDUCATION OF DENTISTS

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A profession belongs to its educational process. Dentistry is defined by how each dentist is educated. Dentistry in the United States has benefited incalculably from the report by Gies,² which solidified the special relationship of dentistry to the university and to schools of medicine. Only 150 years ago, no American university considered dentistry to be a learned profession. As late as the 1930s, licensure in dentistry continued to be available to those who had never attended dental school. Proprietary, "storefront" dental schools were the source of education of many dentists until well into the 20th century. In some other countries, storefront dental schools remain today. In those settings, dentists do not practice a medical profession. For example, they do not write prescriptions, do not serve on hospital medical or dental staffs and are not integrated into the fabric of overall health care as resources for good health. In an environment in which dental education is not integrated into medical education, the public suffers from dentistry that is not biomedically based. Inadequate clinical diagnosis, poor infection control and a lack of clinical skills are the result.

The United States built a different model of education of dentists that became predominant in only the last 80 years. By now, much of the world has followed our model. Emulation of American dental education has reached the point at which foreign dental schools now seek recognition and accreditation for their American-style dental education. Dentistry grew in the United States as a profession linked first to the best private universities in the country and subsequently to the premier public universities. This evolution became complete in the late 1970s, when the last wave of public universities opened dental schools that were linked to academic health centers. In the past decade, three new dental schools have opened: two private schools at Nova Southeastern University and the Arizona School of Dentistry and one new public dental school at University of Nevada, Las Vegas. Two of these are linked to full-service universities and two are linked to medical schools on the same campus.

Recognition of the essential and inexorable link between medical and dental education has been expanded by the report of the Institute of Medicine called Dental Education at the Crossroads.³ In this report, the Committee on the Future of Dental Education recommended that "to prepare future practitioners for more medically based modes of oral health care and more medically complicated patients, dental educators should work with their colleagues in medical schools and academic health centers" to expand joint educational experiences in clinical and basic sciences and to expand joint degree programs.^3(p13)

In contrast, the other professions that have elected to call their members "physicians" (such as "chiropractic physician," "podiatric physician" and "naturopathic physician") have essentially no significant presence in the great private and public universities and little presence in academic health centers. Their educational programs exist in a near-proprietary setting. Students of these professions do not have access to the full breadth and scope of health care education. They are hampered by an educational philosophy and even a theory of pathophysiology that does not encompass the full breadth and scope of knowledge and understanding of human disease.

These other professions do not share with medicine its education in basic science. However, these other "physician" professions do seek to provide treatment for the same diseases that allopathic (M.D.) and osteopathic (D.O.) physicians seek to treat. Only allopathic and osteopathic physicians can be licensed in medicine, as it is generally understood by the public. The titles accepted by licensing boards vary from state to state. In some instances titles are limited; in others, some of the self-appointed "physician" professions are not even licensed. These changes in professional monikers continue to be a source of debate and confusion in state legislatures and on licensing boards.

Dentistry, in contrast, has benefited from a shared view of science and disease processes developed in a shared environment in America’s academic health centers. For dentistry to emulate these other "physician" professions, it would cast aside more than a century of shared education, as well as a shared understanding of disease based on the scientific method. Dentistry would do so only to become physician pretenders, emulating health disciplines without educational recognition or status based upon the rigorous requirements of academe.

	THE PROFESSIONAL IDENTITY OF DENTISTS

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The dental profession, the public, physicians, the other health professions, government and industry all have failed to completely understand the role of dentistry and the necessity of good oral health in preserving overall health. All have suffered to some extent owing to this failed communication. Dentists continue to struggle with their profession’s identity and their role in their patients’ health. The public has only a rudimentary understanding of the critical issues of oral health. Physicians and practitioners in the other health professions do not understand their own roles in oral health and do not take responsibility for oral health issues in their patients. Government and industry develop separate standards for oral health, as if the mouth could be physically separated from the body. The result is a population that does not get the full benefits of good oral health. Everyone would benefit if the professional identity of dentists was solidified and better understood.

Fortunately, even in the absence of a generally recognized professional identity for dentists, the members of the dental profession have developed an exciting, eclectic and important health care profession that is well-positioned to serve the needs of the public. It also is a profession that is, in fact if not in name, the anatomically regionally based practice of medicine and surgery. Consider these instances from the real professional activity of dentists.

– Dentists share with physicians the responsibility for postoperative hemostasis after oral procedures. New technology to enhance local hemostasis has emerged in dentistry to limit the compromises that must be made in pharmacologically induced anticoagulation. Dentists are able to offer treatment that does not require the gross alteration of therapeutically indicated anticoagulation. The result is less risk of stroke, embolism or myocardial infarction in the at-risk population receiving necessary dental care.⁴

– Dentists in Manitoba developed a tobacco-use cessation program to serve the 79 percent of smokers in the province who reported that they wanted to quit using tobacco. They also successfully incorporated a fee code for tobacco-use cessation services to support the promulgation of this effort.⁵

– Survival after a diagnosis of oral cancer has not improved in decades, due to the failure to identify the disease at an earlier stage of diagnosis. Only early detection with a nonsymptom-driven screening visit can detect oral cancer at a stage at which it can be treated effectively with minimal morbidity and mortality. Dentists receive intensive education in early diagnosis of oral cancer. The American Dental Association has mounted a public information campaign supporting early diagnosis. Dentists are twice as likely to make a correct clinical diagnosis of oral cancer in a clinical setting as are physicians.⁶ Dentists are far more likely than are physicians to make a referral for oral cancer after a nonsymptom-driven visit by a patient.⁷ Indeed, in one study, no physician made any incidental (nonsymptom-driven) referrals for oral cancer to a head and neck specialist, while all incidental diagnoses of oral cancer were made by dental professionals.⁷

These examples demonstrate that dentistry has developed an important identity as a fully responsible, scientifically based, anatomically focused medical profession linked to medicine. Dentistry has a special relationship with medicine, while it continues to benefit from a distinct professional identity. The medical literature is beginning to evidence recognition of dentistry’s essential role in an anatomical region that medicine is not able or willing to incorporate into its scope. In Academic Medicine, the journal of the American Association of Medical Colleges, Hendricson and Cohen⁸ recognized the need for expanded training in systemic disease pathophysiology and a practice scope for dentists that recognizes the overlapping therapeutic needs of patients.

A principal challenge for the future is to bolster the understanding that physicians have of oral diseases and of the role of dentistry in the health of their patients. In a recent survey, only 40 percent of family physicians recommended that a child make his or her first dental visit by the age of three years.⁹ Both health care providers and the public have only a rudimentary understanding of the services provided by dentistry and its scope of practice.^10,11 Physicians are a primary source of health information for their patients. One of the best ways in which dentists can support the role of their profession is to communicate well with physicians. Changing the moniker of "dentist" to "oral physician" will not support that goal.

	THE NEEDS OF THE PUBLIC

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In its Future of Dentistry report, the ADA¹² wisely reflected on the role and responsibilities of the dental profession. The report states that the mission of the dental profession is "to guard the oral health of the public."^12(p3) Dental education and medical education in American academic health centers combine to serve the totality of human disease, using the scientific method. For dentists to call themselves "physicians," dentistry must merge completely with medicine and grant the M.D. degree. Is that a good idea, one that will serve the needs of the public?

Dentistry’s survival as a separate profession is not owed to self-interest. Dentistry was not made a separate profession because it was easier than medicine or because the intensity of intellectual endeavor, treatment complexity or patient management issues associated with it was somehow less than that in medicine. Dentistry’s well-kept secret is that it is a separate profession precisely because it is too demanding and too resource-intense to be simply another specialty of medicine.

Is it hubris to believe that dentistry is more of a challenge to the health professions than is cardiology or neurosurgery? Consider that Manski and colleagues¹³ found that patients’ office costs for dental services were similar to those for medical services. If one removed the hospital setting, testing and imaging, and allied health profession expenses, patients spent as much on dental care as medical care.¹³ At least the present dental work force, 150,000 dentists, is needed to meet the needs of Americans’ oral health. That is more than many times the work force need for any other surgical specialty (since no oral surgical specialty has one-tenth that number of members). Without early bonding to dentistry, as is provided by contemporary American dental education, an insufficient number of physicians in an oral physician model would seek careers as dentists (or oral physicians), thus leaving the public without essential services.

A profession does not exist to serve itself. Indeed, many of the actions that might serve the members of the profession best will not serve the public well. Yet those things that serve both the public and the profession best from the beginning are the only things that have the staying power to be effective in the future. Consider the immense need for oral health care now and in the years ahead. The need for oral health services is expected to rise in the future—a real surprise to those who anticipated that scientific breakthroughs would eliminate the principal oral diseases by now.¹³ Consider also that it is only in recent decades that the public and policy-makers have begun to place the appropriate value on their oral health as integral to human health. The Surgeon General’s Report on Oral Health indicated that oral health needs are among the most unmet health needs of Americans.¹⁴ Dentistry will be subject to extremely high demands in the future to serve the needs of an expectant public.

	THE CHANGING HEALTH CARE LANDSCAPE

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Emerging technology surely will change the oral health needs of patients in the coming decades. The Future of Dentistry Report recommends an elastic work force size to reflect these potential changes.¹² If the need for dentists were to be reduced by 10-fold in the future, it is likely that a combination of existing medical and surgical specialties could attend to the oral health needs of patients. However, three generations of scientists (since the founding in 1948 of the National Institute of Dental Research, now the National Institute of Dental and Craniofacial Research) have not been able to attain this goal. Designing a profession for this hypothetical future might be worse than premature if the goal of biomedical research is not achieved. Many of today’s oral health needs can be addressed only with invasive surgical techniques such as restorative dentistry. Only a technological breakthrough of major proportions will alter this fact.

The health care economy is in crisis. The United States spends a higher portion of its gross domestic product, or GDP, on health care than does any other country.¹⁵ Health care expenses now are 15 percent of the U.S. GDP, and more than 40 million Americans have no health insurance.¹⁵ The health care system, especially the payers and public policy-makers, are unwilling to extend recognition to education programs or professional identity that will add further cost to the system. Controlling patients’ utilization of care (limiting access), emphasizing prevention and providing less expensive services are the guiding principles for the third parties that pay for health care. The move toward an "oral physician" program can only add costs to a system that already is bloated. The history of medical and dental degree programs that have been combined to create oral physicians has been tarnished by the loss of graduates to traditional medical surgical specialties. Recently, every enrollee in the University of Kentucky’s oral physician program sought a career in medicine. Combined-degree programs work best for dentistry when their students are highly committed intellectually and clinically to the endeavor. Students who already have earned the dental degree may be more committed to staying in dentistry after completing a combined-degree program. That likely is the reason that such attrition is not observed in combined-degree oral and maxillofacial surgery programs, less than 10 percent of the graduates of which leave dentistry.¹⁶ A return to the term "oral physician" proposed by Dr. Giddon would be, at best, ill-timed. It would be a costly endeavor and result in a poor yield of oral health care professionals.

Dentistry has the advantage of having controlled costs and maintained the doctor-patient relationship better than has any other profession in health care. Do we truly serve the profession and the public best by emulating the problems that exist in the other health care professions? If dentists call themselves physicians, they are likely to be treated as physicians.

	ETHICAL COMMUNICATION

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The opportunity to care for another human being, especially with the invasive techniques of surgery, creates unique obligations on the part of the caregiver. Clear and unambiguous communication about one’s qualifications to perform a procedure is necessary if the patient is to make an informed decision about whether to accept treatment.

Patients clearly have a better idea of how to assess the recommendations of a dentist than those of a person who presents himself or herself as an "oral physician." A new title for an existing health care professional serves to obfuscate important treatment decisions, confuse patients and misinform the public.

The irony is that dentistry has done a poor job of communicating the scope of knowledge, skills and services involved in being a dentist. Failure to communicate this effectively to the public creates the converse problem of reducing patients’ expectations regarding their visits to a dentist. The public needs to be better informed that the basic medical science education and medical surgical skills of dentists are not confined to one anatomical region, but are holistic. The pharmacology, microbiology and pathophysiology of dental practice are as broadly based as those involved in the practice of medicine. For example, the dentist’s obligation in infection control does not differ from that in any other physician encounter. The need for medical evaluation and medical decision-making before embarking on treatment is no less complex in the dental setting than it is in other health care settings.

All ethical decisions must be made by individual people, not by groups or professions. When a person sees a dentist, the dentist must convey his or her qualifications to the patient personally. The dentist also must present himself or herself individually to the public. If a dentist uses an unconventional moniker such as "oral physician," it may promote a visceral response in those who are proud of their identity as dentists. In my observation, where the "oral physician" experiment has been attempted, it has proven divisive.

The new title "oral physician" might augment our sense of self-worth, but it will deceive the public. See its effect in an exchange one might imagine at a future parent-teacher association event:

Parent 1: "This kids’ career day is a lot of fun, isn’t it?"

Parent 2: "Yes, I’m a civil engineer, and as a mother I think it’s great to show our daughters what we can accomplish. What do you do?"

Parent 1: "Oh, I’m an oral physician."

Parent 2 (jokingly): "Is that some kind of doctor who actually talks to her patients?"

Parent 1: "Uh, no! We help make our patients healthy by making their mouths healthy."

Parent 2 : "So you’re a dentist?"

Parent 1: "Oh, no! Let me explain!"

This complicated type of exchange always occurs when people do not say what they mean. Obfuscation for an ulterior purpose or to aggrandize one’s position falsely does not serve to communicate well and can create a sense of distrust.

	SUMMARY

TOP THE DENTIST’S SCOPE OF... THE REPOSITIONING OF PARAMEDICAL... BECOMING ‘ORAL... SUMMARY REFERENCES FOOTNOTES  THE EDUCATION OF DENTISTS THE PROFESSIONAL IDENTITY OF... THE NEEDS OF THE... THE CHANGING HEALTH CARE... ETHICAL COMMUNICATION SUMMARY REFERENCES

 
Dentistry is not an allied health profession. It is not a paramedical profession. It is time that dentistry be recognized as the profession that offers patients some of the most complex surgery performed on the human body—namely, restorative dentistry and rehabilitation of the masticatory system. Dentistry is the only anatomically focused health care profession that is university-based and for which primary care responsibility is maintained by the profession.

An inferiority complex about what it means to be a dentist has served only to confuse the public and bring us further from our goal of improving the health of all our patients. This inferiority complex is driven by the public and the medical profession, neither of which understands how dentistry fits into overall health care.

It is essential that every academic health center have oral health education as an integrated part of health care education for dentists, physicians, nurses, allied dental personel, physical therapists, psychologists and all who receive university-based health care education. In this way, all the health professions and the public will see dentistry and oral health as essential to patients’ overall health.

The idea of emulating those who do not have the strength of basic-science education, practice complexity, surgical skills or community status by seizing a new title will not elevate the profession for the future. The public knows what a dentist is. It is our task to inform the public about the capabilities of dentists and the value of oral health and our profession. We can accomplish this best by assuring that our profession’s name, "dentistry," is understood to represent one of the world’s most accomplished surgical endeavors, one that is thoroughly integrated into the fabric of health care. Thus, good oral health will be thoroughly integrated into what it means to be healthy.