By Barry Levy, DDS
When the dental profession retains provincial ideas about how the profession is to be run and fails to address problems that exist, the idea of reciprocity between states in America becomes an issue that may slowly gain traction, but hasn’t been addressed in a manner that deals with disasters that can affect those that practice.
While members ask for reciprocity, the profession has failed to address several quality of care issues, failed to have a codified system of regulations that isn’t dependent on zip code, size of practice, number of employees or type of practice, and have allowed unlicensed dentists to practice for expediency’s sake.
It is no wonder that we can’t accomplish certain changes when we have ceded control of a profession to others. And those that make the rules may not be especially interested in what is best for the profession and for the patients in a unified way.
So as Hurricane Katrina has left, and we are left to rebuild, one has to focus on the problems that occur when our highly fragmented profession has placed so many obstacles in the way of dentists wishing to relocate. Whether it is a personal choice, or due to circumstances beyond their control. Reciprocity is the first issue that comes to my mind because of the devastation that has occurred as the aftermath of Hurricane Katrina. And while this article was written during the most dire news reports, the issues become worth examining no matter how the events of the tragedy play out.
Reciprocity is a key issue that has its roots in questions about why different states have different standards of care and try to foster the perception that one state is better than another is.
Why is it that we don’t have one standard for the profession, but instead have various standards?
Why do regulations vary from zip code to zip code, and depend on size of practices, or number of employees, or other basically irrelevant concepts that have nothing to do with the care given to patients?
Are we that caught up with people trying to protect their turf, and trying to do so in ways that make no sense in the long run?
In some regards our profession should take a page from McDonalds. It doesn’t matter where you go. If you see that name, you know that the quality will be the same. It doesn’t vary because of location, size of restaurant, or number of people served.
Quality of Care
The quality of care is a focal point in this discussion. It is the issue that is cited to make reciprocity more difficult, but if one examines the issues of quality of care, one will see that this may be a straw issue.
There are cases of states allowing unlicensed dentists to practice in certain situations on patients. So much for the need of a license or even the appearance of checking for quality of care. There is the issue of states allowing licensed dentists, or dental groups to stay in business when the quality of care is substandard.
So much for the quality of care issue.
But we, as a profession, have sanctioned this substandard care of patients. We have failed to demand quality for all patients. We have been complacent in the problems we want changed by giving a wink and a nod to those offices that harm patients. So while allowing patients to be harmed, and being happy to have the remakes of that poor care, we have harmed the image of our profession.
Will this change? Probably not until we as a profession become proactive to weed out those practices that constantly harm patients.
Allowing substandard care is not how a profession is supposed to maintain their professional standing. Indeed allowing clinically non-acceptable treatment while professing to be concerned about the patient’s safety and quality of treatment leads a non-professional to only see a turf war, not a profession striving for excellence.
It is not acceptable to cast aspersions about the quality of care by others while ignoring the glaring problems in your own backyard.
If we start with the problem of reciprocity, one must ask why a qualified dentist in one state is not accepted by another state. If the issue is quality of care, why do we have individual states setting dental standards rather than the ADA?
This immediately sets the licensing of a dentist as a turf battle where one state can comment that their dentists are better, and keep out others to eliminate some of the potential competition.
While on the issue of quality of care, one must start to question the legitimacy of any dental board examination that doesn’t test what the dentist does and how he treats his patients, especially for a specialist. A general practice board exam, given to a specialist, is not a test of competency, but an attempt to keep a person out. This should have outraged a profession, but it didn’t seem to do so.
The argument has been that the state wants to assure that competent dentists treat patients. So if the issue is quality treatment and the “assumed” protection of the patients, one then has to ask why dental groups that treat in a substandard manner are allowed to keep practicing, even after years of state review indicating that treatment is clinically not acceptable.
What should be the profession’s response to state licensing agencies that know of the problem and continue to license those offices? How long can a profession know of the problems and not be proactive to solve those problems?
Would it make you upset that large groups, treating in a substandard manner are allowed to stay in business because the state wants some place for the patients to be seen?
How long should a group that is treating patients in a non-clinically acceptable manner be allowed to work with the problem?
In one case that I am aware of, the state has been working with the poor quality of treatment given to patients for over 13 years, with the harm continuing. Where is the professional outrage about the abuse of patients? Do you start to understand that allowing the poor quality of care is starting to harm the profession? It sets up a two-tier level of care that must be unacceptable.
When the profession doesn’t step up and do what is proper, others will take the lead, and the result may be that reciprocity doesn’t happen, while substandard quality of care may be the norm. It’s time to change this, especially as we turn more and more into a global community while more and more patients are even looking to seek treatment outside the US.
Reciprocity for Displaced Dentists
As our colleagues are displaced, and may have to find work outside their home state, this has brought this issue into the forefront of issues that need consideration.
Why isn’t a valid dental degree sufficient to practice in any state?
With the devastation of Hurricane Katrina, and the potential displacement of so many colleagues this issue has become critically important, and immediately so. Many of our colleagues may be forced to relocate to different states in order to survive, but will they be able to practice their profession, and do so immediately. Will they be given immediate reciprocity?
Because reciprocity wasn’t the norm in the past we have now placed ourselves in a serious Catch-22 problem. If reciprocity is given to any displaced dentist by another state we must ask why there is a waiver to do so. If we accept reciprocity for financial betterment of the dentist that needs it, that exception would show that the whole problem was a straw issue.
If an exception is given in this case, then the reasoning for not having reciprocity will have been shown to be a bogus one, because then the profession will be dealing with economic need of some colleagues and the issue of public safety will not have been a consideration.
We are caught in a bind. Doing what is right for our colleague brings the issue to a head. Either this is acceptable and hasn’t been allowed or we have lost sight of our patients’ well being to better ourselves. The confusion over this issue will leave our patients to question what is happening. Are we looking out for their best interests or for our own? When patients perceive that we aren’t looking out for them, that is when the profession starts to have problems.
So now we come to Hurricane Katrina and what we as a profession are going to do to help our colleagues get back on their feet, and to earn a living, while practicing their profession. Should we give reciprocity to those dentists whose practices have been destroyed without licensing them? If we do, then we must question why they are qualified because of a disaster, and if feelings are the proper reason to allow this.
If we allow them to practice because we feel their pain, then the whole issue of licensing becomes moot, because a precedent has been set for reciprocity. If we allow them to practice without a license, is that state going to stand behind what they did, by any rationalization?
If the state is going to license them by saying that they are qualified without a license from that state, or that particular board, because they state they are qualified, then we get back to square one of why the dental license isn’t accepted without the paperwork and costs that are now in place.
Protecting the Profession
I have written in past articles that when a profession doesn’t have set standards and doesn’t protect itself and those patients that they treat, then others will come into the vacuum that is created. Those people that start to make the rules and regulations, may not be dentists, and may not have the profession’s best interests, or even the patient’s best interests at heart. When we cede that control to others, we stop becoming a profession and become a trade association. Something that I think that we have studied too long and too hard to strive for, to have taken away by others.
We are being forced to realize that as a profession, we have abdicated our professional responsibility. We have allowed others to dictate what we should be doing, most notably lawyers. Just check to see the language of the dental practice act, and who wrote those laws. Try making sense of HIPPA regulations, or OSHA standards, or even better the absurdity of some of the rules set by CDC.
I especially like the ruling that extracted teeth must be treated as hazardous waste materials and disposed of properly, unless, get ready for this, you give the tooth to the patient. Then the tooth is no longer a hazardous waste material. Can you imagine this scenario in an operating room?
In the wake of the problems with dentistry that have been allowed to flourish, from poor quality to state sanctioned mills that harm patients, to absurd rules and regulations, we have brought a lot of problems to our profession that will continue to emerge as we become more of a global community. We have petty turf squabbles over how many dentists we should license and who we should license. This completely ignores the issue that our profession should not be engaging in trade restrictions, or looking to protect our turf to the detriment of others.
Ever wonder why dental boards are political appointments rather than our profession selecting the best people to serve this capacity? Do you think it might be time to question this practice, and ask if those on dental boards should be political cronies, and fat cat contributors, or the best people possible that can serve the public and our profession?
National and International Dentistry
A story in USA Today mentioned how patients are seeking treatment outside the country because of costs. And the response from the dental establishment was that you get what you pay for, and that the quality of care in the United States is the best in the world.
But aren’t there different fees in different areas of local communities and different states? Can a legitimate argument be made that reciprocity has been a tool to dictate different standards of care in different areas? So shouldn’t a patient be a good consumer and shop for the best price? And aren’t fees different in different areas?
While we say that the quality of care in the United States is the best, aren’t we aware of the fact that there are problems with certain dental “mills” that have been allowed to practice with no particular outrage from the profession about the quality of care that those patients receive in those offices?
The typical dental response is that if you go to a foreign dentist you may have no recourse should a problem arise. That is not much different from the cases not taken by lawyers because the amount of the damages isn’t worth the legal time. It is truly fortunate for the profession that so many dental malpractice cases normally fall out of the realm of cost return that lawyers want.
Or how about the recent case where the patient was harmed, but the lawyer dropped the case just before trial because they found that the dentist had no assets, or insurance?
We should be asking for uniform standards in our global community and uniform standards that quickly and efficiently resolve the problems with poor quality. It is wrong to cast stones about the quality of care in foreign countries, when accepting clinically unacceptable treatment here. It is wrong to claim that there would be no recourse, when that is often the case here.
We should be taking the lead, to show patients that, while mistakes happen, they will be
corrected, and quickly. That would be a profession taking the lead.
I have seen peer review take so long that the statute of limitations can expire while waiting for a ruling. It is also wrong to have the policy for peer review forcing the patient to forego any possible legal solution. That becomes similar to informed consents that force arbitration. It is not a positive way to approach the problems that we have allowed to happen.
Have you ever worked at a dental mill, knowing that you were not doing the best quality that you could, and accepting it?
I remember when 60 Minutes did a program on this issue. The dentist was very smugly telling how bad those clinics were, and that he worked there in order to pick up speed and experience, but he would never work like that again. But nowhere did he take the initiative to inform patients of the problems, or to report the problem to the proper regulatory agencies. So he, and all that know of the problem with the quality of care, are doing their best to create the climate where the profession is harmed.
Ever think that allowing this poor quality may be the reason that we aren’t as strong as we should be? Ever have second thoughts about how our profession sanctions offices that harm patients, while we smugly practice in our private offices, willing to do the remake on these patients, but not willing to correct the problem? Ever wonder if this attitude is what has caused consumer groups to start to question what happens in our offices, and lobby for changes to be made?
In California there was a guest worker program being established which would allow non-licensed dentists to come into California to treat the large Mexican population. The allegation was that this population wasn’t getting proper treatment. Seemed that in the discussion to allow this, the state was making the argument that California-licensed dentists were not being sensitive enough to the dental needs of those that weren’t American citizens.
So a breach in the licensing requirement was being made, while the profession remained strangely silent. This type of agreement, which allows unlicensed dentists to treat patients, but won’t give a licensed dentist reciprocity, is a dual system that should have the profession up in arms. As should the concept that California dentists don’t have the sensibilities to treat the Hispanic population.
In Arizona, I recall that dentists that didn’t want to be in private practice could opt out of having to get an Arizona license if they were to only practice in state-run dental clinics, and accept a much lower form of compensation.
While not as egregious as the California situation, consider what the state is saying: “You don’t need a state license if you are going to treat the poor, but if you are going to treat paying patients you must be licensed.”
Either the dentist is qualified or he isn’t, but to make the determination based on the income of the patient, has already set up the two-tier level of treatment that should be abhorrent to all professionals.
Australia allows assistants to place amalgams, but only on children. Are the assistants qualified or are they not? Or is there a difference in the teeth of children when compared with adults? Different standards, based on obscure reasoning and based on monetary concerns, should be a red flag.
Two Tier Treatment
Does this mean that the two-tier level of treatment is being created by de facto arrangements that the profession is not a party to and are these two-tier levels of care becoming the norm?
This reminds me of the situation that should you have HMO type plans to fill in your empty time, you may have created a two-tier level of treatment in your office. That could create a serious nightmare, if and when it gets shown that you don’t treat all with the same skill, care, and in the same timely manner.
We may already be going into an interesting direction where licensing will be done by post dental internships. New York has a new requirement that an internship is needed after dental school, replacing the licensing examination.
Is the standard of care going to be the internship after dental school, to replace dental boards, and will that be done in all states?
This program raises the specter of where all these programs will be held, and will all dentists be able to get into a program. If you add the number of dentists to a location, have you artificially created, by government mandate, an adverse economic condition for all those that are already practicing? And what do you do if there is no internship program in a state, or there is not access to the program? Will we now have a two-tier level for licensing and for those with an internship and those taking boards? Will foreign dentists that want to practice here also have to apply for the intern program?
The Bigger Issue
In any case, the bigger issue should be what do we do about reciprocity, and how do we handle it in a timely manner so that we don’t have to face these decisions in time of a crisis. What are we going to do to bring the rest of the global dental community into conformity with standards that are being established? Isn’t it time to get rid of the notion that our profession is a profession that has different standards based on where we choose to practice?
We are in interesting times, and again, because we as a profession have stuck our collective heads in the sand, events are dictating to us, what should have been the profession taking care of their patients and their profession.
While centering my discussion around the events caused by Hurricane Katrina and offering prayers and support for all those affected, we should also be sending our prayers to our colleagues in Mumbai, India. In July that community suffered severe flooding that killed more than a thousand people. They also are looking at an estimated $690 Million to repair the structural damages done by that flooding.
(Contributing writer Dr. Barry Levy is a dental consultant, lecturer and is on the California Dental Board’s panel of expert witnesses for dental board investigations)