I am writing on behalf of my constituent dentists from the Fourth District, whom I represent on the ADA Council of Government Affairs, regarding their concerns about the March JADA editorial, "Lessons Learned: Implications for Workforce Change" (
JADA 2008;139[3]:232, 234[Free Full Text]
), by Drs. Michael Glick and O.T. Wendel.
I respect the authors’ right to voice their opinion, but I respectfully disagree with their thoughts regarding the so-called "midlevel providers." Furthermore, the timing of this editorial is most unfortunate. To write this editorial in the midst of the debate over the advanced dental hygiene practitioner (ADHP) bill in the state of Minnesota stands in direct opposition to the positions of the American Dental Association and the Minnesota Dental Association.
The inconsistency between Dr. Glick’s opinion as the editor of dentistry’s premier journal versus what the ADA is trying to achieve "on the ground," at great expenditure of both time and financial resources to defeat this ill-conceived legislation, is confoundingly evident. At the very least, it sends a confusing message to our members and, in my opinion, gives aid and comfort to those who support this bill, which, if enacted into law, will negatively affect our great profession.
This bill is proposed under the guise of access to care but, as originally written, has absolutely no requirements for ADHPs to practice in under-served areas. Remember, the same arguments about access were used to secure a bill for unsupervised hygiene in Colorado, where today only one of the 17 unsupervised hygienists’ practices is located in an underserved area. The editorial also states that "academic dental institutions must assume a leadership vote in this evolutionary process." However, please note that the ADHP bill takes the educational process out of dental schools and places it in community colleges and universities.
Comparing dentistry’s situation to the "similar evolution of the medical profession ... as nurses, physician assistants and nurse practitioners struggled to define their ... roles in health care" is a weak analogy. The aforementioned midlevel practitioners generally do not invasively cut human tissue in their daily practices. As we dentists know, using a high-speed rotary turbine in the oral cavity is not only a difficult, but also an exacting and precise, skill for professionally trained dentists, and could easily lead to irreversible damage to patients if performed by individuals who lack this expertise.
In addition, I would not be in favor of these "practitioners" performing simple extractions. In my many years of clinical practice, I have seen so-called simple extractions turn out to be complex situations that can involve profuse hemorrhaging and require surgical excision of osseous tissue. Medical emergencies involving allergic reactions, syncope and even potentially fatal situations also can occur.
The authors write about the recent evolution of medicine as if it was a positive event. Many physicians who experienced the "evolution of the medical profession that began in the 1970s" think the new model is a debacle for their profession. They feel the practice of medicine is now basically controlled by the insurance industry, and it doesn’t work effectively for their patients. They state that this industry controls patients’ choice of doctors and reduces fees paid to physicians to fund its record profits. Ironically, some physicians claim that the only group that seems to be flourishing during this evolution is the midlevel providers.
Our profession should not endorse dental midlevel providers. We already have a system in our efficient private practices to solve the access problem. Once organized dentistry has convinced our government to reimburse dentists in all states at reasonable levels for Medicaid patients, the problem will be well on its way to being solved.
