The following article, written in 2000, is about my experiences in the Indian Public Health Service 37 years ago. Today, in light of the turmoil and resistance surrounding the government’s long overdue bid to overhaul the health care delivery system of the United States, this article is timely even today. Even though there have been some positive changes in federal and state funded programs for this and other long-neglected populations that have limited access, I believe that inequality in the delivery of proper dental care still exists.
I have a confession to make. When I was in dental school in the early 1970’s, I had very lofty dreams. The Vietnam War was winding down, and it was a time of peace and love and caring for your fellow man. As a senior, I researched many possibilities that would allow me to earn a living as a dentist while serving humankind. I felt that I could fulfill those dreams by either working in a dental clinic or operating a mobile dental van in the low-income inner city or rural areas where good dentistry was hard to find. Then I learned about a position that could be the answer to all of my conditions.
When I graduated from Georgetown Dental School in 1973, I chose to enter the Indian Public Health Service. I thought that it was an ideal program in which I could further my education and begin a lifetime of service to my community. I was sent to The Fort Berthhold Indian Reservation 5 miles from Newtown, North Dakota. My family and I were given a three-bedroom house, which was on a compound with ten other homes and a clinic. One physician and several other health professionals including myself, social workers and nurses lived in the other houses. It was wonderful. After all, work was a short walking distance, and we had a full view of the Missouri River from our window and wild horses galloping in the fields among the beautiful Dakota buttes. I was very excited about living in such a beautiful and spiritual land with my family and happy with the prospect of helping people who wouldn’t otherwise receive dental care. More important was the knowledge that I did not have to rely on charging fees for my skill or creating a high volume practice in order to survive. It wasn’t long before my bubble burst and the bureaucracy and prejudice of the system became apparent.
The basics of dental treatment, including examinations, cleanings, fillings and extractions, were offered. Other more costly services which may have been necessary to save teeth such as endodontics (root canal therapy), crown and bridge, partial or full dentures and periodontal (gum and bone) treatment required pre-approval similar to pre-authorizations needed for insurance companies. Children were usually approved for the basics, but treatment for adults, particularly those who needed a combination of root canal treatment with crown and bridge, were rarely approved.
Because of the small population of the reservation (4000) and the limited budget of the program, some physicians and dentists, like myself, were recruited right out of dental school and were placed in a very difficult situation, whereby they found themselves as the sole providers of their specialty of health care in the facility. Inexperienced dentists did not have the benefit of further hands-on education working with others in their profession who possessed more experience, for consultations, or for doing more difficult procedures. Obviously, my skills were limited and my patients were the unfortunate beneficiaries of my learning curve. For the first time, I understood the true meaning of the term, ” to practice dentistry.”
Based on the economics of the system, Indian Public Health often recommended extraction (removal) of teeth and partial or full dentures. The same is true in similar instances where low income patients receiving government sponsored Medicaid benefits or patients with private or employee benefits dental insurance could be refused necessary tooth-saving treatment simply because it would not be cost beneficial to save the teeth. Even though many patients are helped by these programs and may not otherwise be able to afford even basic dental treatment, recommendations based on cost-effectiveness and profit margin is wrong. It often resulted in the removal of marginally damaged teeth. This, along with the unfortunate, but inevitable, mistakes of a rookie dentist, created a cycle of mistrust between this dentist and his patients.
The creation of trust and love between the dentist and the patient is one of the most important elements of the successful relationship within the dental environment. I laugh when I think of how naïve I was. I tried to work around the system by applying for tooth-saving benefits for adults. They were rejected. I wrote articles on dental health and nutrition for the clinic news bulletin. It fell on deaf ears. I tried to teach my patients home care and gave them nutritional advice. Not many cared. I created a children’s dental health week poster contest and gave away solicited prizes such as toothbrushes and floss to the winners. Very few children entered. I went on a local TV show called “Bowling for Dollars” and several radio shows in order to spread the message. It made no impact. It became more frustrating for me as time went by. I realized that years of abuse and neglect by the system wasn’t going to be eliminated by a Jewish white boy from New York. This lack of “love and trust” often showed as very fearful patients, or an excessive number of broken appointments, or great difficulty filling the appointment book. But, the bottom line was that the missing piece was “love and trust.” They didn’t trust me. They didn’t love me.
Even though we dentists are trained to save teeth, our efforts are very often curtailed by the patient’s insurance or their participation in a government-sponsored program such as Medicaid. Either a yearly benefit maximum or limitations within the individual plan often determined the actual treatment plan. The obvious answer, still unaccomplished to this day, is national dental health insurance in which all of our citizens have access to the best dentistry available. As with the continuing debate over national medical health insurance, it is important that the end result be that quality of care does not suffer or be limited by affordability. Until that happens, where do dentists, especially the private practitioners who may accept some insurances or government subsidies as payment in full, and who must make a living from the profits of his or her practice, fit into the equation?
Dental fees are determined by many factors. Up to two-thirds of dental income is determined by the overhead expenses needed to run the office. This includes telephone, heat, electricity, dental materials, instruments, books, magazines, furniture, equipment, laboratory, payroll, continuing education courses, accounting, liability and health and malpractice insurances. It made no difference to my lab or to my dental supplier whether I was getting a full fee or accepting a lower fee. All of these costs must be controlled in order for the business of dentistry to survive.
In dental school, I was taught that if I wanted to earn a good living from the dental profession, I had to work quickly and efficiently and render as much treatment as possible in a visit. For example, doing four fillings in an hour is more cost effective than doing two forty-five minute visits of two fillings each. Sometimes that meant pushing the envelope and doing too much. There is a contradiction that exists when health professionals depend upon either a large volume of patients or higher fees for their livelihood. One visit endodontics (root canal therapy), multi-quadrant (more than one area) crown and bridge preparation or gum and bone surgery is not only traumatic during the procedure, but can result in more post-operative complications and discomfort for the patient. Too often, large volume means poor quality. Unfortunately, high fees don’t always extrapolate into better quality and service. Very often the patient feels ” ripped off” by the high fee or poor quality and no longer trusts the dentist specifically or the profession as a whole.
Sadly, even today, in The United States of America, there are few places for an individual with little means to receive quality care. Dental Schools offer their students’ services at a lower cost and teaching hospitals do have interns and residents that may provide quality care at a lower cost. Medicaid can provide children from low-income families with basic dental needs. Adults, with Medicaid, however, can fall through the cracks and receive even less necessary dental care. Like a carpenter or a plumber who possesses great skills, a dentist should be properly compensated. Dentistry is providing treatment to relieve pain or allow a person to smile or chew their food, which are basic human needs. It is a sham that in the richest country on this earth, the system allows the treatment of choice to be determined by ones financial status.
The modern concept that “time is money” can encourage dentists to schedule long appointments. The reasons sound plausible. Once the patient is anesthetized, it is better to do as much as you can. This can result in fewer visits, which is something patients do appreciate. However, the physical and psychological stress it can cause for the patient should be taken into account. Due the pressure of a busy schedule, there is little time for explanation of treatment. This can leave the patient at a disadvantage when it comes to making intelligent decisions on their dental care. The stress on the TMJ, the musculature, the necessity of using more anesthesia and the difficulty of getting a correct bite when more than one area is numb are just some reasons not to do too much treatment in one visit.
Look around the dental office the next time you have an appointment. What’s missing? Uncomfortable business chairs or couches are in the waiting room. The appropriate three-month-old Time or Newsweek magazines are on a table or in a rack on the wall. Some newspaper or magazine articles about saving teeth are attached to a bulletin board with pushpins. Some hallmark thank-you cards or hand-made thank you gifts are prominently displayed. You are led into the “operatory” and seated in a large vinyl chair. In front of you are packages of sterile instruments. Boring muzak is pumped into the room. The dentist wearing a mask and latex gloves enters. There are a few minutes of small talk. They explain the treatment scheduled in a foreign language and proceeds. What is missing? In my opinion, “love and trust” is missing.
Most dentists, though in the profession for obvious financial rewards do have a deeper reason for choosing their field. They truly want to help and heal people. Yet, they are often perceived as being aloof, insensitive and impatient. Unfortunately, all of us some of the time or some of us all of the time, may treat patients like a mouth with teeth and a wallet instead of a whole person who needs to be respected and loved. Unfortunately, this can increase a patient’s fear and distrust and dislike of dentists, which can create an environment in which many patients will seek only emergency treatment and give empty promises of returning for regular care. Patients may use time, money or fear as the excuse. But it is a lack of love and trust that keeps them away. In my opinion, it would better serve the dental profession and their patients if “love and trust” replaced the concept of “time is money.”
