- Email: [email protected]
HISTORICAL PERSPECTIVE
LETTERS
LETTERS JADA welcomes letters from
readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, doublespaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
LICENSURE REFORM
Edward gibbon began his investigation of the decline of the Roman Empire by focusing on the crux of the issue. The real question for him was not why the empire declined and fell, but why it lasted so long. We have a similar situation in dentistry. Everybody keeps focusing on the question of why we should revise the current system of licensure instead of asking the right question: Why has the current Byzantine system of licensure been allowed to last so long? I have great respect and admiration for the dedicated members of the state and regional dental boards. Over the years, their endeavor to improve and refine the current system of licensure is commendable. But my perspective would be that the current system is inherently defective and cannot be significantly improved by the actions of those who operate it. We have many problems in dentistry today, including the challenge of managed care, decreased need for traditional dentistry, increased litigation, spi-
raling overhead, theft in the office and so on. The question might rightly be asked how so many of us manage to keep it all together under the present circumstances. We have undergraduate dental programs in the United States that are inspected and certified by the ADA. We have a written national board examination. Is that not enough? It is in almost every other G7 country in the world to have internal geographical restrictions on the practice of dentistry. Again, the question I pose is not why should we change the system, but why has the current system, clearly restrictive of free trade, been allowed to last so long? How about taking all those resources that go into licensing and putting them where we really need them? How about creating more programs to help dentists suffering from substance abuse or emotional problems? How about using those funds to expand existing programs? How about making continuing education more accessible and cheaper? How about putting those funds into mentor programs and study clubs? And let us not forget the reality of dentists in the real world. It is hard to make a living, and it is hard to deal with competition. But I would like to think that the Rev. Martin Luther King Jr. had the right idea about us all going forward together. Well, that is really not happening in dentistry, where we continue to march in the opposite direction. My point would be that the current system fails to do something that it does not need to do in the first place, and that, in supporting the current system, we draw off assets that could be better applied to help us all.
We should have had a simple national system of licensing years ago. There is no excuse or justification for maintaining the current system. We need to start thinking about the evolution of our profession and its place in the 21st century. It’s time for all of us to go forward together. Gary Kaplowitz, D.D.S. Baltimore CACHET, NOT CASH
I enjoyed your editorial in March JADA (“And Then There Were None”), but I think your perspective is wrong. According to your article, you think Northwestern University’s dental school closure is due to a shortage of cash, not “cachet” (prestige). I think the opposite: I think the university trustees view the entire dental profession with a lack of appreciation or understanding. They do not know a phantom head from a panoramic radiograph or an MOD from a PFC, and they think of dental college in the same terms as barber college, totally unsuitable for a prestigious university. Once, in a candid moment years ago, an NU trustee told me that with my NU undergraduate education, it would be a “waste of my abilities and education to go into dentistry.” That the economic argument does not hold is apparent when one considers that NU trustees are ever more ready to squander vast sums on the men’s athletic program, despite its laughable failure for at least five decades. Fred E. Ehrlich, B.A., D.D.S. Lynnwood, Wash. HISTORICAL PERSPECTIVE
Thanks, Dr. Meskin, for your
JADA, Vol. 129, July 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
817
LETTERS carefully researched editorial, “And Then There Were None.” With all the information contained in your editorial, I found it easy to suggest a solution to the closing-of-dental-schools problem. Perhaps it is not a problem at all that dental schools are closing. Perhaps it is the best solution at this time. It is natural for institutions to want to perpetuate themselves and grow, but sometimes a reduction is in the best interests of the profession they represent and the public they serve. Even the institution can benefit. Certainly, the university benefits by closing a money-losing division, the dental school. More than 20 years ago, the federal government decided to produce more dentists to maintain some imagined ideal dentist-to-population ratio, at that time. This, they reasoned, would cause dentists to spread out across the country and bring dental care to underserved areas. They also believed it would reduce dental fees through competition. They were wrong. This was the beginning of the flouride era. Caries restoration was about to become 15 percent or less of a dental practice’s income—instead of 85 percent as it had been. Furthermore, increasing the number of dentists does not increase the demand for dentistry. It simply forces more dentists to practice where there is a demand. It also does not lower fees. It raises them, because the dentist must still earn an adequate income to pay rents, taxes, salaries and lab costs and still have enough left over for a professional’s living standard. The schools gladly accepted the federal funds, although there 818
was some discussion in the beginning about losing autonomy and, although it was obvious that fluoridation was a successful public health measure, reducing the need for dentistry. Now, after more than two decades of social engineering of the worst kind, we find too many dentists treating too little disease, at great cost to themselves and the public. This has left most new graduates vulnerable to managed care. The overproduction of dentists is also the basis for the problems of student debt. As the schools grew, so did their operating costs. The government gave money to expand buildings, not operating costs. As you point out, running a dental school is more costly than running a medical school. There is an optimum size for any institution that was quickly surpassed as the federal government continued to pour money into a bottomless pit, without re-evaluating the need. As the cost of a dental education skyrocketed, so did the tuition, loading down the dental students with incredible debt. I suggest that a gathering be called to re-evaluate the socalled dentist-population ratio, the number and location of dental schools and how to best maintain this ratio based on need and to efficiently utilize always-scarce resources. This symposium should be recalled every five years to re-re-evaluate resources and need. Alvin D. Jacobs, D.D.S. New York SUPPLY AND DEMAND
Reading the April Question of the Month (“Should Organized Dentistry Act to Reverse the Closing of Dental Schools?”), I appreciated the well-thought-out
article and rational reasons why organized dentistry should not become involved. My only real exception was the thought that if “practitioners are not available, HMO types will not be far behind.” Somehow this seems convoluted reasoning to me. I think the real reason HMOs continue to exist is because there are too many practitioners in the marketplace. I have yet to see any large accumulation of practicing dentists who feel there is a manpower shortage from the dental side. My personal thoughts are that this is a supply-and-demand situation. And after having experienced the capitation growth of dental schools, it’s time for the pendulum to swing in the opposite direction. As a dues-paying member of the ADA for 25 years, I feel that at times the Association has not been responsive to the practicing dentist to the degree that it should be. This has been in favor of the teaching dentists, the political dentists, the insurance dentists and other ADA members who compose smaller percentages of the overall dental population. Perhaps this is why such a low percentage of the total licensed dentists actually belong to the American Dental Association. If only 17 percent of our membership believed this is an issue that organized dentistry should address, I would find it just short of reprehensible if any of our dues money were to support an effort that was so clearly a minority position. C.R. Hoopingarner, D.D.S. Houston Editor’s note: For the record, the most recent figures (1997) show that ADA membership is about 73 percent, far ex-
JADA, Vol. 129, July 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
LETTERS JADA welcomes letters from
readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, doublespaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
LICENSURE REFORM
Edward gibbon began his investigation of the decline of the Roman Empire by focusing on the crux of the issue. The real question for him was not why the empire declined and fell, but why it lasted so long. We have a similar situation in dentistry. Everybody keeps focusing on the question of why we should revise the current system of licensure instead of asking the right question: Why has the current Byzantine system of licensure been allowed to last so long? I have great respect and admiration for the dedicated members of the state and regional dental boards. Over the years, their endeavor to improve and refine the current system of licensure is commendable. But my perspective would be that the current system is inherently defective and cannot be significantly improved by the actions of those who operate it. We have many problems in dentistry today, including the challenge of managed care, decreased need for traditional dentistry, increased litigation, spi-
raling overhead, theft in the office and so on. The question might rightly be asked how so many of us manage to keep it all together under the present circumstances. We have undergraduate dental programs in the United States that are inspected and certified by the ADA. We have a written national board examination. Is that not enough? It is in almost every other G7 country in the world to have internal geographical restrictions on the practice of dentistry. Again, the question I pose is not why should we change the system, but why has the current system, clearly restrictive of free trade, been allowed to last so long? How about taking all those resources that go into licensing and putting them where we really need them? How about creating more programs to help dentists suffering from substance abuse or emotional problems? How about using those funds to expand existing programs? How about making continuing education more accessible and cheaper? How about putting those funds into mentor programs and study clubs? And let us not forget the reality of dentists in the real world. It is hard to make a living, and it is hard to deal with competition. But I would like to think that the Rev. Martin Luther King Jr. had the right idea about us all going forward together. Well, that is really not happening in dentistry, where we continue to march in the opposite direction. My point would be that the current system fails to do something that it does not need to do in the first place, and that, in supporting the current system, we draw off assets that could be better applied to help us all.
We should have had a simple national system of licensing years ago. There is no excuse or justification for maintaining the current system. We need to start thinking about the evolution of our profession and its place in the 21st century. It’s time for all of us to go forward together. Gary Kaplowitz, D.D.S. Baltimore CACHET, NOT CASH
I enjoyed your editorial in March JADA (“And Then There Were None”), but I think your perspective is wrong. According to your article, you think Northwestern University’s dental school closure is due to a shortage of cash, not “cachet” (prestige). I think the opposite: I think the university trustees view the entire dental profession with a lack of appreciation or understanding. They do not know a phantom head from a panoramic radiograph or an MOD from a PFC, and they think of dental college in the same terms as barber college, totally unsuitable for a prestigious university. Once, in a candid moment years ago, an NU trustee told me that with my NU undergraduate education, it would be a “waste of my abilities and education to go into dentistry.” That the economic argument does not hold is apparent when one considers that NU trustees are ever more ready to squander vast sums on the men’s athletic program, despite its laughable failure for at least five decades. Fred E. Ehrlich, B.A., D.D.S. Lynnwood, Wash. HISTORICAL PERSPECTIVE
Thanks, Dr. Meskin, for your
JADA, Vol. 129, July 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
817
LETTERS carefully researched editorial, “And Then There Were None.” With all the information contained in your editorial, I found it easy to suggest a solution to the closing-of-dental-schools problem. Perhaps it is not a problem at all that dental schools are closing. Perhaps it is the best solution at this time. It is natural for institutions to want to perpetuate themselves and grow, but sometimes a reduction is in the best interests of the profession they represent and the public they serve. Even the institution can benefit. Certainly, the university benefits by closing a money-losing division, the dental school. More than 20 years ago, the federal government decided to produce more dentists to maintain some imagined ideal dentist-to-population ratio, at that time. This, they reasoned, would cause dentists to spread out across the country and bring dental care to underserved areas. They also believed it would reduce dental fees through competition. They were wrong. This was the beginning of the flouride era. Caries restoration was about to become 15 percent or less of a dental practice’s income—instead of 85 percent as it had been. Furthermore, increasing the number of dentists does not increase the demand for dentistry. It simply forces more dentists to practice where there is a demand. It also does not lower fees. It raises them, because the dentist must still earn an adequate income to pay rents, taxes, salaries and lab costs and still have enough left over for a professional’s living standard. The schools gladly accepted the federal funds, although there 818
was some discussion in the beginning about losing autonomy and, although it was obvious that fluoridation was a successful public health measure, reducing the need for dentistry. Now, after more than two decades of social engineering of the worst kind, we find too many dentists treating too little disease, at great cost to themselves and the public. This has left most new graduates vulnerable to managed care. The overproduction of dentists is also the basis for the problems of student debt. As the schools grew, so did their operating costs. The government gave money to expand buildings, not operating costs. As you point out, running a dental school is more costly than running a medical school. There is an optimum size for any institution that was quickly surpassed as the federal government continued to pour money into a bottomless pit, without re-evaluating the need. As the cost of a dental education skyrocketed, so did the tuition, loading down the dental students with incredible debt. I suggest that a gathering be called to re-evaluate the socalled dentist-population ratio, the number and location of dental schools and how to best maintain this ratio based on need and to efficiently utilize always-scarce resources. This symposium should be recalled every five years to re-re-evaluate resources and need. Alvin D. Jacobs, D.D.S. New York SUPPLY AND DEMAND
Reading the April Question of the Month (“Should Organized Dentistry Act to Reverse the Closing of Dental Schools?”), I appreciated the well-thought-out
article and rational reasons why organized dentistry should not become involved. My only real exception was the thought that if “practitioners are not available, HMO types will not be far behind.” Somehow this seems convoluted reasoning to me. I think the real reason HMOs continue to exist is because there are too many practitioners in the marketplace. I have yet to see any large accumulation of practicing dentists who feel there is a manpower shortage from the dental side. My personal thoughts are that this is a supply-and-demand situation. And after having experienced the capitation growth of dental schools, it’s time for the pendulum to swing in the opposite direction. As a dues-paying member of the ADA for 25 years, I feel that at times the Association has not been responsive to the practicing dentist to the degree that it should be. This has been in favor of the teaching dentists, the political dentists, the insurance dentists and other ADA members who compose smaller percentages of the overall dental population. Perhaps this is why such a low percentage of the total licensed dentists actually belong to the American Dental Association. If only 17 percent of our membership believed this is an issue that organized dentistry should address, I would find it just short of reprehensible if any of our dues money were to support an effort that was so clearly a minority position. C.R. Hoopingarner, D.D.S. Houston Editor’s note: For the record, the most recent figures (1997) show that ADA membership is about 73 percent, far ex-
JADA, Vol. 129, July 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.