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Emerging profiles in total health care
Emerging Profiles in Total Health Care Leroy E. Burney,* M .D ., M .P .H ., Philadelphia
Total health care means the complete quality, availability, comprehensiveness, health needs of the people, irrespective costs and financial accountability. o f who or what profession contributes to 6. Medical and dental manpower meeting these needs. The term “ compre shortages will continue, requiring in hensive health care” has the same conno creased production and utilization of aux tation and includes preventive, curative iliary health personnel. and restorative health services applied to 7. Patterns of care and the demand to the total, or whole, person, family or narrow the yawning gap between knowl community. edge and its application will require the I will risk the role o f prophet, list my addition of members of other disciplines predictions, and then try to explain them. to our health team and greater interde 1. The members of the health profes pendence of action in providing total sions will come to recognize that they care. are social scientists and as such will be 8. Hospitals will become the major affected more and more by the dynamic focus for health services— the real com economic, social and political factors in munity health center. society. 9. Specialization will become even 2. Health care will become more and more a dominant characteristic of dental more a basic right, not just a privilege. and medical practice. 3. Comprehensive health care, pre ventive, curative and restorative, will be our objective, with the greatest emphasis on prevention. 4. Progress in health care creates in creasing demand and utilization. These result in changing patterns of care and higher costs. 5. Governmental influence — local, state, and federal— through increased re sponsibility in reimbursement for care, will result in more controls related to
10. Schools of dentistry and medicine rightfully will assume greater and, hope fully, more imaginative responsibility for continuing education. H E A LTH IN TRANSITION
The past 20 years have brought more changes than any other period in history — change and growth in the material means of life— changes in political, social and economic problems. These significant changes are due in large part to the
74/56 • THE JO U R N A L OF THE A M E R IC A N DENTAL ASSO C IA TIO N
miraculous progress of science and tech nology. Whether this dominant force of science will be a blessing or a disaster will depend on the use men make of science. The health sciences have played a ma jor part in these changes. In the same breath, one must recognize that two yard sticks of good health— increased longevity and lower mortality rates— have been more favorably affected by higher eco nomic levels, improved environment and preventive biologies than by the more dramatic and respected curative health practices. This is not to minimize the value of curative practices, but to maxi mize the greater importance of preventive health services, undramatic and unap pealing as they may be. This theory is as valid for the chronic illnesses and disabili ties, the primary concern for the present and future, as it was in the past for the infectious diseases. Therefore, for the fu ture in total health care, greater empha sis will be placed on prevention. It is comparatively simple to apply the science and technology of the physical sciences for material gains. It is much more difficult to apply successfully the output of the biologic and health sciences. They provide the tools for someone else to use. These new tools are coming out of the laboratories in increasing numbers as rewards for the millions, or even bil lions, expended or yet to be spent in the future. These dollars have been and will be a sound investment. But their promise has not been fulfilled by performance. This is true because we are dealing with people, people with differing attitudes, emotions, and social, cultural, educational and economic levels. Is it due also, and perhaps even more so, to the fact that, when compared to the funds and person nel utilized for basic research, there is a lack of emphasis and funds, as well as effort given to advancing more success ful application of the knowledge emanat ing from our laboratories and clinical research? The public will come to know that it is not fully realizing its investment in
research and will demand that the chasm between knowledge and application be narrowed, that the science and practice of application catch up with the science of the laboratory. W e will be forced into programs, almost, if not wholly, crash programs of research in methodology, in patterns of health care, in organization and administration, involving compre hensiveness, continuity, quality and econ omy of care. Medicine and dentistry are social sci ences, phenomena of society, and not dis tinct and separate from it. Although these professions, more than others, guide and shape the direction o f health services, the final decision is made by the public. Therefore, services developed to serve so ciety must be based on an understanding of its needs. This understanding is vital in applying effectively the vast body of knowledge in the health sciences by the medical and dental professions. This application, in turn, requires that we look outside the antiseptic walls of our classrooms, laboratories, clinics, offices and hospitals to learn what is happening in society, the social, political and eco nomic changes occurring, and how these affect our application o f knowledge. We have not done enough of this— we talk too much to ourselves— we resist change instead o f recognizing its inevitability and attempting to give it sound and in telligent direction. There is too much of an inclination to back into the future in stead of facing it squarely, its challenges and its opportunities. C H A N G IN G S O C IE T Y
What are some of the changes in society? The size and character of the popula tion are changing constantly. It is predominantly an urban popula tion; about three out of every four per sons live in one of 184 metropolitan com munities. It is a highly mobile population; 35 million people change their residences every year.
BURNEY . . . VOLUME 68, JA N U A RY
The economy is primarily industrial. The educational and economic levels of society have increased. Health has be come a basic right, not just a privilege. This results in greater utilization of health services, creating in turn changes in patterns of health care, comprehen siveness, and concern with quality. The increasing role o f third-party pay ments for health care, especially govern mental, has important implications. In the medical and dental professions, certain changes are noted in addition to the wealth of new knowledge. The hospital is rapidly becoming the focus for the provision of health care, within and without its walls— the real community health center. Specialization has become a dominant characteristic and a factor in the provi sion of health care. The increasing utilization of the allied health professions— oral hygienists, chairside assistants, laboratory and x-ray tech nicians, physical and vocational therapists — plays a vital role in the provision of health services. If it is agreed that schools of dentistry and medicine will not in crease in size or numbers sufficiently to maintain even the present ratio of the medicodental professions to population, then expansion and greater utilization of these allied health specialists will be re quired. In the complex society of today and to morrow, the professions o f dentistry and medicine need to use the social and be havioral sciences more than ever before to accomplish the objectives of total health care. There is now, and will be even more so in the future, a greater requirement for interdependence within the health pro fessions and with some disciplines tradi tionally considered outside. The explosion of new knowledge makes it impossible for the mathematician to know the whole of mathematics or the physicist to know the whole of physics; nor, for the same reasons, can the den tist or physician know the whole of
1964 •
75/57
health. As the health sciences advance, new fields are added, resulting in frag mentation of old ones. One example is to be found in the basic sciences. In the study o f cellular genetics, biochemistry is required— knowl edge of immunity at the cellular and molecular levels, chemical structure of the molecule and antibodies, and many other facets. Biology, chemistry, mathe matics, physics and pharmacology are all essential. It is a mistake to emphasize one over the other. Rather, there is a cross fertilization, an amalgamation and meld ing of the various sciences so they become almost indistinguishable. New syntheses are breaking down the traditional barriers of academic departments. The separate compartments of the chambered Nautilus are dissolving into one larger and more useful chamber. Hopefully, there is some cross-fertiliza tion beginning in the application of knowledge. Acceleration is required. U n derstandably, this is not as simple as in the laboratory where the scientist is deal ing with test tubes and animals. The achievement of cross-fertilization is not impossible, however, but necessity re quires that more be done. Physicians and dentists must make things happen and not wait for them to happen. This is true professional leadership. It also helps to preserve the freedom and quality of health services. A C T IO N N E C E S S A R Y
What do these emerging profiles in total health care mean to representatives from schools of dentistry, health departments, private practice, and related areas, as suming the sketch is substantially accu rate? What are their opportunities as health care is visualized in transition? W ould it be agreed that the barriers of the past between science and the world of practical affairs are crumbling— that this is inevitable and desirable? Then, if the various forces are drawing physicians and dentists into the center o f the stream
76/58 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA TIO N
o f life, is their first question how to bridge the gulf between research and application in their service, teaching and research programs? H ow can the walls be broken down between the academic departments and among the schools in a university; how do dentists and physicians synthesize and catalyze the relations among all of those concerned in providing total health care to meet the needs of society? Is there a need for new organizational patterns as the common core o f science becomes broader and the gap between knowledge and application hopefully shortens— patterns in teaching, service and research to reflect the facts o f life? Organization alone cannot solve the prob lems, but it does provide a mechanism to reflect existing situations and permits members of the health professions to be more responsive to the progress of the health sciences and dynamics o f their society. If the needs of the public for compre hensive health care and continuity of care are to be met, each member of the medicodental professions has to overcome the problem not only o f isolation from society outside his doors, but also of his remote ness from others in the health sciences, from practitioner, health agency and edu cational institution. T oo many teaching institutions are in the community, but not o f it. Many believe that the responsi bilities in continuing education are dis charged by having some graduate semi nars. H ow can the practitioner be brought in on research efforts, to gain the depth of knowledge he has of people, families and neighborhoods? I f there is still some thing to the dentist-patient and physi cian-patient relationship, this rich reser voir should be tapped in research related to patterns of health care. The belief that science is basic to den tistry and medicine has resulted in its almost complete domination of profes sional education— undergraduate, gradu ate and postgraduate. Admitting this value and importance, the subjective, interpersonal comprehensive physician-
patient, dentist-patient relationship is the real foundation o f dentistry and medi cine, yesterday, today and tomorrow. It is often said that medicine and dentistry are arts based on the sciences, but the art is disappearing rapidly. Collectively, great stress is placed on this physician-patient, dentist-patient relationship, but what does it really mean in today’s highly ur banized, mobile society? It still has a real meaning, though a different one, than a generation ago, and an attempt should be made to redefine it and emphasize it in medicodental education and practice. A physician was called to see an elderly patient in his home. The man had com plained o f rectal bleeding. Like many older people who are slightly senile, he had a compulsion to have a daily bowel movement, but because of his confused state, he could not remember whether one had occurred. H e had begun by using mild laxatives and ended by taking stronger ones— hence the rectal bleeding. The physician took him off. medicine, put a calendar in the bathroom where the old man could mark off when he had a bowel movement. This solved the prob lem. Here was not highly technical skill, complicated diagnostic equipment or new miracle drugs. This was treatment of the whole person with the warm personal touch. This was simple medicine, but it was also the physician at his best. A mother brought her 14 year old daughter in to see their family physician. She complained that her daughter was growing too fast. The physician had de livered the youngster. He had cared for the whole family; he knew them, their education and culture, their language and their problems. H e did not reach for scales or a height chart because he knew that the mother was concerned that her 14 year old daughter was leaving child hood and approaching young woman hood, and the mother needed help in in structing the girl in the facts o f life. Imagine a specialist or a strange physi cian with this depth of understanding and awareness.
BURNEY . . . VOLUME 68, JA N U A RY 1964 • 77/59
How can the attitudes of the faculties of many professional schools and the practitioners be changed to recognize that health departments have a real contribu tion to make in research and demonstra tion, in the organization and manage ment o f service, and are not something set apart and concerned only with regulatory and enforcement functions? As the hospital becomes more and more the community health center, what will be the relation of dental care in this setting for inpatients and ambulatory pa tients? In the planning and development o f total health care services to the aged and chronically ill in their homes and in paramedical institutions, the dental pro fession has an important contribution to make. Without it, care is not compre hensive and the needs o f the people are not being met. Someone has noted that in a city of several million people, fewer than 150,000 women took advantage of the cell cytol ogy test for uterine cancer, despite its well-demonstrated effectiveness as an early screening technic and life-saving procedure. Fluoridation of public water supplies is not advancing rapidly. Other preventive health care services are not being used well. How do dentists and physicians motivate people, change their attitudes and responsiveness? The medi cal and dental professions are just learn ing to use the social and behavioral scien tists as a part of their team— this requires acceleration. The public is becoming concerned with quality— and the costs— of health care, particularly as they relate to third-party payments. What controls other than fiscal will occur with increasing governmental reimbursement for care? These relate es pecially to hospital care and to such issues as overconstruction of beds, overutiliza tion, and costs o f care related to quality and comprehensiveness. Some control goes with any dollars— voluntary or gov ernmental. What is the responsibility of city, state or federal government to es tablish accounting standards and mini
mum criteria for quality of care if they are reimbursing for such care? This con cern exists now. It will increase in the months to come. Can it be said that gov ernment, if it pays for care, has no other responsibility? If it is agreed that govern ment has, how can the medicodental pro fessions insure that these standards and criteria are sound and reasonable ones and that enforcement is kept close to home? Should dentists and physicians de velop these standards and criteria first instead of having such controls forced on them? In the emerging profile of total health care in our country, these are con troversial issues. They cannot be dodged, nor totally opposed. In the development of our own system, consonant with our culture, tradition, resources and needs, the answer certainly is not to assign the problem to the government, nor can it be assumed, with increasing tax dollars available for the purchase o f care, that the government— federal, state or local— has no interest or concern. Real leader ship is required from all the health pro fessions to resolve these issues within our system of freedom and private enterprise, at the same time recognizing that those in the health professions cannot act in a vacuum. What does this emerging profile of total health care mean; what actions are de manded? Most of the deans and faculties of schools of dentistry graduated 20 or 25 years ago. Scientific knowledge has more than kept abreast of the passing years, but have teaching methods and curricula content? Are schools meeting the needs of next September’ s freshmen to face a constantly changing and dynamic society o f 1967? What does greater utilization of health care mean in a rising population? Does it require an examination o f the output o f dentists and auxiliary dental man power— can it actually be said that classes of 50 or 60 or 75 dental students are all that can be produced, or all the instructor wants to have? Can costs be justified for
132/114 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA TIO N
Emerging Profiles in Total Health Care (Burney)— continued from page 59.
this number in the light of the great de mand? What are the blocks to increasing the number of oral hygienists and dental assistants? Is a training environment be ing provided for students to teach them the most efficient utilization of their talents and time? How can the sometimes conflicting demands of primary educa tional responsibility and those scholarly concerns with research and graduate training be digested? Have these become the major status symbols? T h e impor tance of research and graduate training in a scholarly environment cannot be ques tioned— overemphasis, imbalance can be. What is going to be done about re search in patterns of health care, in qual ity of care, in comprehensiveness of care? The initiative can come from any one with the idea— the essential factors are to recognize the need and to have a will ingness to work together— the practicing dentist, the health agency, the school, and others outside of one’ s own profession, including the medical school and hos pital. What role can be envisioned for the social and behavioral scientists? Gan they help those in the health professions to a better understanding of human behavior, motivation, attitudes, so promise and per formance can be brought closer together?
CONCLUSION
There is an expression that “ the happy man is one who lives in the past.” A bet ter comment is found in Hawthorne’s House of Seven Gables: “ The world owes all its onward impulses to men ill at ease.” Whether the emerging profiles of total health care presented here are ab stract art or have some validity, there is some hope that the members of the medi cal and dental professions will remain respectful of the past but “ ill at ease” for the future. Then they will be prepared to make things happen, not just wait for them to happen. These are the marks of a great profession— this must occur if these professions are to meet the needs of people in transition, and, equally impor tant, if the fine traditions and freedom of these professions are to be preserved and enhanced. If the members of these profes sions do not act, rest assured that some one will. The will of the people is like a grist mill— it grinds slowly, but it grinds inexorably.
Keynote a ddre ss presented at the Fourteenth N ational Dental H ealth C onference, spo nsore d by the C o u n cil on Dental H ealth of the A m e ric a n Dental A ssocia tion , in C h ic a g o , A p ril 22 to 24, 1963. *V ice president of health sciences, T em ple University; form erly Su rge on G eneral, United States Public Health Service.
Total health care means the complete quality, availability, comprehensiveness, health needs of the people, irrespective costs and financial accountability. o f who or what profession contributes to 6. Medical and dental manpower meeting these needs. The term “ compre shortages will continue, requiring in hensive health care” has the same conno creased production and utilization of aux tation and includes preventive, curative iliary health personnel. and restorative health services applied to 7. Patterns of care and the demand to the total, or whole, person, family or narrow the yawning gap between knowl community. edge and its application will require the I will risk the role o f prophet, list my addition of members of other disciplines predictions, and then try to explain them. to our health team and greater interde 1. The members of the health profes pendence of action in providing total sions will come to recognize that they care. are social scientists and as such will be 8. Hospitals will become the major affected more and more by the dynamic focus for health services— the real com economic, social and political factors in munity health center. society. 9. Specialization will become even 2. Health care will become more and more a dominant characteristic of dental more a basic right, not just a privilege. and medical practice. 3. Comprehensive health care, pre ventive, curative and restorative, will be our objective, with the greatest emphasis on prevention. 4. Progress in health care creates in creasing demand and utilization. These result in changing patterns of care and higher costs. 5. Governmental influence — local, state, and federal— through increased re sponsibility in reimbursement for care, will result in more controls related to
10. Schools of dentistry and medicine rightfully will assume greater and, hope fully, more imaginative responsibility for continuing education. H E A LTH IN TRANSITION
The past 20 years have brought more changes than any other period in history — change and growth in the material means of life— changes in political, social and economic problems. These significant changes are due in large part to the
74/56 • THE JO U R N A L OF THE A M E R IC A N DENTAL ASSO C IA TIO N
miraculous progress of science and tech nology. Whether this dominant force of science will be a blessing or a disaster will depend on the use men make of science. The health sciences have played a ma jor part in these changes. In the same breath, one must recognize that two yard sticks of good health— increased longevity and lower mortality rates— have been more favorably affected by higher eco nomic levels, improved environment and preventive biologies than by the more dramatic and respected curative health practices. This is not to minimize the value of curative practices, but to maxi mize the greater importance of preventive health services, undramatic and unap pealing as they may be. This theory is as valid for the chronic illnesses and disabili ties, the primary concern for the present and future, as it was in the past for the infectious diseases. Therefore, for the fu ture in total health care, greater empha sis will be placed on prevention. It is comparatively simple to apply the science and technology of the physical sciences for material gains. It is much more difficult to apply successfully the output of the biologic and health sciences. They provide the tools for someone else to use. These new tools are coming out of the laboratories in increasing numbers as rewards for the millions, or even bil lions, expended or yet to be spent in the future. These dollars have been and will be a sound investment. But their promise has not been fulfilled by performance. This is true because we are dealing with people, people with differing attitudes, emotions, and social, cultural, educational and economic levels. Is it due also, and perhaps even more so, to the fact that, when compared to the funds and person nel utilized for basic research, there is a lack of emphasis and funds, as well as effort given to advancing more success ful application of the knowledge emanat ing from our laboratories and clinical research? The public will come to know that it is not fully realizing its investment in
research and will demand that the chasm between knowledge and application be narrowed, that the science and practice of application catch up with the science of the laboratory. W e will be forced into programs, almost, if not wholly, crash programs of research in methodology, in patterns of health care, in organization and administration, involving compre hensiveness, continuity, quality and econ omy of care. Medicine and dentistry are social sci ences, phenomena of society, and not dis tinct and separate from it. Although these professions, more than others, guide and shape the direction o f health services, the final decision is made by the public. Therefore, services developed to serve so ciety must be based on an understanding of its needs. This understanding is vital in applying effectively the vast body of knowledge in the health sciences by the medical and dental professions. This application, in turn, requires that we look outside the antiseptic walls of our classrooms, laboratories, clinics, offices and hospitals to learn what is happening in society, the social, political and eco nomic changes occurring, and how these affect our application o f knowledge. We have not done enough of this— we talk too much to ourselves— we resist change instead o f recognizing its inevitability and attempting to give it sound and in telligent direction. There is too much of an inclination to back into the future in stead of facing it squarely, its challenges and its opportunities. C H A N G IN G S O C IE T Y
What are some of the changes in society? The size and character of the popula tion are changing constantly. It is predominantly an urban popula tion; about three out of every four per sons live in one of 184 metropolitan com munities. It is a highly mobile population; 35 million people change their residences every year.
BURNEY . . . VOLUME 68, JA N U A RY
The economy is primarily industrial. The educational and economic levels of society have increased. Health has be come a basic right, not just a privilege. This results in greater utilization of health services, creating in turn changes in patterns of health care, comprehen siveness, and concern with quality. The increasing role o f third-party pay ments for health care, especially govern mental, has important implications. In the medical and dental professions, certain changes are noted in addition to the wealth of new knowledge. The hospital is rapidly becoming the focus for the provision of health care, within and without its walls— the real community health center. Specialization has become a dominant characteristic and a factor in the provi sion of health care. The increasing utilization of the allied health professions— oral hygienists, chairside assistants, laboratory and x-ray tech nicians, physical and vocational therapists — plays a vital role in the provision of health services. If it is agreed that schools of dentistry and medicine will not in crease in size or numbers sufficiently to maintain even the present ratio of the medicodental professions to population, then expansion and greater utilization of these allied health specialists will be re quired. In the complex society of today and to morrow, the professions o f dentistry and medicine need to use the social and be havioral sciences more than ever before to accomplish the objectives of total health care. There is now, and will be even more so in the future, a greater requirement for interdependence within the health pro fessions and with some disciplines tradi tionally considered outside. The explosion of new knowledge makes it impossible for the mathematician to know the whole of mathematics or the physicist to know the whole of physics; nor, for the same reasons, can the den tist or physician know the whole of
1964 •
75/57
health. As the health sciences advance, new fields are added, resulting in frag mentation of old ones. One example is to be found in the basic sciences. In the study o f cellular genetics, biochemistry is required— knowl edge of immunity at the cellular and molecular levels, chemical structure of the molecule and antibodies, and many other facets. Biology, chemistry, mathe matics, physics and pharmacology are all essential. It is a mistake to emphasize one over the other. Rather, there is a cross fertilization, an amalgamation and meld ing of the various sciences so they become almost indistinguishable. New syntheses are breaking down the traditional barriers of academic departments. The separate compartments of the chambered Nautilus are dissolving into one larger and more useful chamber. Hopefully, there is some cross-fertiliza tion beginning in the application of knowledge. Acceleration is required. U n derstandably, this is not as simple as in the laboratory where the scientist is deal ing with test tubes and animals. The achievement of cross-fertilization is not impossible, however, but necessity re quires that more be done. Physicians and dentists must make things happen and not wait for them to happen. This is true professional leadership. It also helps to preserve the freedom and quality of health services. A C T IO N N E C E S S A R Y
What do these emerging profiles in total health care mean to representatives from schools of dentistry, health departments, private practice, and related areas, as suming the sketch is substantially accu rate? What are their opportunities as health care is visualized in transition? W ould it be agreed that the barriers of the past between science and the world of practical affairs are crumbling— that this is inevitable and desirable? Then, if the various forces are drawing physicians and dentists into the center o f the stream
76/58 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA TIO N
o f life, is their first question how to bridge the gulf between research and application in their service, teaching and research programs? H ow can the walls be broken down between the academic departments and among the schools in a university; how do dentists and physicians synthesize and catalyze the relations among all of those concerned in providing total health care to meet the needs of society? Is there a need for new organizational patterns as the common core o f science becomes broader and the gap between knowledge and application hopefully shortens— patterns in teaching, service and research to reflect the facts o f life? Organization alone cannot solve the prob lems, but it does provide a mechanism to reflect existing situations and permits members of the health professions to be more responsive to the progress of the health sciences and dynamics o f their society. If the needs of the public for compre hensive health care and continuity of care are to be met, each member of the medicodental professions has to overcome the problem not only o f isolation from society outside his doors, but also of his remote ness from others in the health sciences, from practitioner, health agency and edu cational institution. T oo many teaching institutions are in the community, but not o f it. Many believe that the responsi bilities in continuing education are dis charged by having some graduate semi nars. H ow can the practitioner be brought in on research efforts, to gain the depth of knowledge he has of people, families and neighborhoods? I f there is still some thing to the dentist-patient and physi cian-patient relationship, this rich reser voir should be tapped in research related to patterns of health care. The belief that science is basic to den tistry and medicine has resulted in its almost complete domination of profes sional education— undergraduate, gradu ate and postgraduate. Admitting this value and importance, the subjective, interpersonal comprehensive physician-
patient, dentist-patient relationship is the real foundation o f dentistry and medi cine, yesterday, today and tomorrow. It is often said that medicine and dentistry are arts based on the sciences, but the art is disappearing rapidly. Collectively, great stress is placed on this physician-patient, dentist-patient relationship, but what does it really mean in today’s highly ur banized, mobile society? It still has a real meaning, though a different one, than a generation ago, and an attempt should be made to redefine it and emphasize it in medicodental education and practice. A physician was called to see an elderly patient in his home. The man had com plained o f rectal bleeding. Like many older people who are slightly senile, he had a compulsion to have a daily bowel movement, but because of his confused state, he could not remember whether one had occurred. H e had begun by using mild laxatives and ended by taking stronger ones— hence the rectal bleeding. The physician took him off. medicine, put a calendar in the bathroom where the old man could mark off when he had a bowel movement. This solved the prob lem. Here was not highly technical skill, complicated diagnostic equipment or new miracle drugs. This was treatment of the whole person with the warm personal touch. This was simple medicine, but it was also the physician at his best. A mother brought her 14 year old daughter in to see their family physician. She complained that her daughter was growing too fast. The physician had de livered the youngster. He had cared for the whole family; he knew them, their education and culture, their language and their problems. H e did not reach for scales or a height chart because he knew that the mother was concerned that her 14 year old daughter was leaving child hood and approaching young woman hood, and the mother needed help in in structing the girl in the facts o f life. Imagine a specialist or a strange physi cian with this depth of understanding and awareness.
BURNEY . . . VOLUME 68, JA N U A RY 1964 • 77/59
How can the attitudes of the faculties of many professional schools and the practitioners be changed to recognize that health departments have a real contribu tion to make in research and demonstra tion, in the organization and manage ment o f service, and are not something set apart and concerned only with regulatory and enforcement functions? As the hospital becomes more and more the community health center, what will be the relation of dental care in this setting for inpatients and ambulatory pa tients? In the planning and development o f total health care services to the aged and chronically ill in their homes and in paramedical institutions, the dental pro fession has an important contribution to make. Without it, care is not compre hensive and the needs o f the people are not being met. Someone has noted that in a city of several million people, fewer than 150,000 women took advantage of the cell cytol ogy test for uterine cancer, despite its well-demonstrated effectiveness as an early screening technic and life-saving procedure. Fluoridation of public water supplies is not advancing rapidly. Other preventive health care services are not being used well. How do dentists and physicians motivate people, change their attitudes and responsiveness? The medi cal and dental professions are just learn ing to use the social and behavioral scien tists as a part of their team— this requires acceleration. The public is becoming concerned with quality— and the costs— of health care, particularly as they relate to third-party payments. What controls other than fiscal will occur with increasing governmental reimbursement for care? These relate es pecially to hospital care and to such issues as overconstruction of beds, overutiliza tion, and costs o f care related to quality and comprehensiveness. Some control goes with any dollars— voluntary or gov ernmental. What is the responsibility of city, state or federal government to es tablish accounting standards and mini
mum criteria for quality of care if they are reimbursing for such care? This con cern exists now. It will increase in the months to come. Can it be said that gov ernment, if it pays for care, has no other responsibility? If it is agreed that govern ment has, how can the medicodental pro fessions insure that these standards and criteria are sound and reasonable ones and that enforcement is kept close to home? Should dentists and physicians de velop these standards and criteria first instead of having such controls forced on them? In the emerging profile of total health care in our country, these are con troversial issues. They cannot be dodged, nor totally opposed. In the development of our own system, consonant with our culture, tradition, resources and needs, the answer certainly is not to assign the problem to the government, nor can it be assumed, with increasing tax dollars available for the purchase o f care, that the government— federal, state or local— has no interest or concern. Real leader ship is required from all the health pro fessions to resolve these issues within our system of freedom and private enterprise, at the same time recognizing that those in the health professions cannot act in a vacuum. What does this emerging profile of total health care mean; what actions are de manded? Most of the deans and faculties of schools of dentistry graduated 20 or 25 years ago. Scientific knowledge has more than kept abreast of the passing years, but have teaching methods and curricula content? Are schools meeting the needs of next September’ s freshmen to face a constantly changing and dynamic society o f 1967? What does greater utilization of health care mean in a rising population? Does it require an examination o f the output o f dentists and auxiliary dental man power— can it actually be said that classes of 50 or 60 or 75 dental students are all that can be produced, or all the instructor wants to have? Can costs be justified for
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Emerging Profiles in Total Health Care (Burney)— continued from page 59.
this number in the light of the great de mand? What are the blocks to increasing the number of oral hygienists and dental assistants? Is a training environment be ing provided for students to teach them the most efficient utilization of their talents and time? How can the sometimes conflicting demands of primary educa tional responsibility and those scholarly concerns with research and graduate training be digested? Have these become the major status symbols? T h e impor tance of research and graduate training in a scholarly environment cannot be ques tioned— overemphasis, imbalance can be. What is going to be done about re search in patterns of health care, in qual ity of care, in comprehensiveness of care? The initiative can come from any one with the idea— the essential factors are to recognize the need and to have a will ingness to work together— the practicing dentist, the health agency, the school, and others outside of one’ s own profession, including the medical school and hos pital. What role can be envisioned for the social and behavioral scientists? Gan they help those in the health professions to a better understanding of human behavior, motivation, attitudes, so promise and per formance can be brought closer together?
CONCLUSION
There is an expression that “ the happy man is one who lives in the past.” A bet ter comment is found in Hawthorne’s House of Seven Gables: “ The world owes all its onward impulses to men ill at ease.” Whether the emerging profiles of total health care presented here are ab stract art or have some validity, there is some hope that the members of the medi cal and dental professions will remain respectful of the past but “ ill at ease” for the future. Then they will be prepared to make things happen, not just wait for them to happen. These are the marks of a great profession— this must occur if these professions are to meet the needs of people in transition, and, equally impor tant, if the fine traditions and freedom of these professions are to be preserved and enhanced. If the members of these profes sions do not act, rest assured that some one will. The will of the people is like a grist mill— it grinds slowly, but it grinds inexorably.
Keynote a ddre ss presented at the Fourteenth N ational Dental H ealth C onference, spo nsore d by the C o u n cil on Dental H ealth of the A m e ric a n Dental A ssocia tion , in C h ic a g o , A p ril 22 to 24, 1963. *V ice president of health sciences, T em ple University; form erly Su rge on G eneral, United States Public Health Service.