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We Privileged Few
EDITORIAL J Oral Maxillofac Surg 73:1237-1238, 2015
We Privileged Few Everyone who receives the protection of society owes a return for the benefit. John Stuart Mill
Last October, I had the privilege to join a host of my fellow colleagues, who had volunteered as oral surgeons, general dentists, and other healthcare providers for the Seattle/King County Clinic. Over 4 days, October 23 to 26, 2014, the KeyArena at Seattle Center—a premiere local venue for musical and sporting events—was converted to a healthcare facility that included a mobile computed tomography unit and the supplies and equipment necessary to provide essential dental, vision, and medical services. Partnering with Remote Area Medical, a global humanitarian organization, 60 organizations came together from across the state of Washington to provide free healthcare. By the end of the weekend, more than 1,500 volunteers had provided $2.4 million of free dental, vision and medical care to 3,386 members of the underserved and vulnerable population of the area, many of whom lined the sidewalks outside KeyArena for days to get access to care.1 It was remarkable to see the floor of the KeyArena— normally reserved for basketball, ice hockey, and concerts—transformed into a massive clinical care environment. The logistics of 60 operatories were remarkably well-planned and well-executed, allowing us to support the delivery of a full range of dental services, from restorative care to imaging, root canal therapy, fabrication of immediate dentures, and tooth extractions. The event also staged more than 40 medical examination ‘ rooms’’ and performed eye examinations, producing 300 sets of prescription glasses each day. Although awkward at first, within seeing my first couple of patients, I was well-acclimated to delivering oral surgery services in the makeshift, transient environment. I am glad I thought to bring my own headlight. The patients proved to be quite remarkable, despite their current adverse circumstances. One patient I met had a very unusual accent. To my ear it was not English, Scottish, or Australian, but a unique combination of them all. While waiting for the local anesthesia to take effect, she filled me in on her background. She was born in Java in the early 1930s, then a Dutch colony located in the East Indies. Her parents were English. In 1942, the Japanese invaded and overran the island. The family was separated and placed in
different prison camps. Only she and her sister survived the war. After liberating the prison camps, the Australian authorities sent the girls to live with foster families, first in Australia and finally in Scotland. Her accent, it turns out, was a composite artifact of these life experiences. Among my pool of patients that day I saw a few who possessed multiple degrees from well-known universities, former small business owners, mechanics, day laborers, artists, musicians, and grandmothers of countless grandchildren. Such was the fabric of this patient population, marginalized on the outskirts of our community, but each possessing a unique story to tell. Their mouths were a direct reflection of the hard times they had experienced. The demographics of the patients we saw were not surprising. Most came to the clinic from the central Puget Sound region. Some, however, had travelled several hours from eastern Washington to reach the clinic. Forty percent of all the registered patients were unemployed. In addition, based on sample data from the patient survey, almost 75% of patients had incomes less than 200% of the Federal Poverty Level. More than one half of all registered patients reported that it had been more than 1 year since their last medical care visit. For greater than 70% of the patients, it had been more than 1 year since their last visit to a dentist. In the survey sample, only one third of the patients reported having any form of medical insurance, and fewer than 10% had dental insurance. There was great comradery among the volunteers, eventually reaching a level of coordination that I love to see on a daily basis in my own clinic. At the end of a long day, we were beyond tired, but felt good about the event and the services we were able to provide. Despite our self-congratulations, however, one question kept nagging at me: had we moved the ‘‘needle’’ on the healthcare needs of King County’s underserved? Notwithstanding this huge logistic adventure in mobile healthcare, I believe the simple answer is ‘‘no.’’ Although both noble and notable, a 1-time, 1-shot effort—even if we continue, as planned, to do this on an annual basis—is an insufficient response to the unmet healthcare needs of this community. Treating the uninsured and underinsured in our community is more controversial than it should be. The vast majority of dentists volunteering their services at our community event were from private practices. However, many of these same clinicians
1237
1238 will not provide services to Medicaid recipients in their own practices. I understand the reason for refusing to accept Medicaid patients. Dental services, particularly in Washington, are grossly undercompensated. It is a challenge even for those of us in academic centers to absorb the underinsured. I cannot help wondering, however, whether we owe society for the privilege of remaining selfregulated. Do we have a professional or moral obligation to absorb the care for those who require services that only we provide? I am not suggesting that we throw open our doors at the expense of fiscal responsibility. However, is not facilitating access to dental and oral and maxillofacial surgical services something for which we are jointly accountable as professionals? Does not regulation tend to occur where groups cannot balance the supply and demand of essential services? If so, perhaps caring for the underinsured is a challenge we should address collectively. How much effect could we have if we all committed a portion of our clinical service (<5%) to caring for the underserved and underinsured in our communities? Academic teaching centers and dental schools are
EDITORIAL
facing greater and greater fiscal challenges, crumbling under the burden of providing a disproportional share of care to the underinsured. Should we consider social obligation the price we pay for self-regulation? Every day I read about clinicians in our specialty and others who provide volunteer care in third world nations. They are the heroes among us. However, it does not take a passport and a series of shots to find people in dire need of healthcare services. Unfortunately, too many can be found in our own backyards. THOMAS B. DODSON, DMD, MPH Associate Editor
Reference 1. Seattle/King County Clinic. October 23-26, 2014. Final Report. Available at: http://seattlecenter.org.media/SKC-Clinic-2014-FinalReport.pdf. Accessed May 18, 2015
Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons http://dx.doi.org/10.1016/j.joms.2015.04.021
We Privileged Few Everyone who receives the protection of society owes a return for the benefit. John Stuart Mill
Last October, I had the privilege to join a host of my fellow colleagues, who had volunteered as oral surgeons, general dentists, and other healthcare providers for the Seattle/King County Clinic. Over 4 days, October 23 to 26, 2014, the KeyArena at Seattle Center—a premiere local venue for musical and sporting events—was converted to a healthcare facility that included a mobile computed tomography unit and the supplies and equipment necessary to provide essential dental, vision, and medical services. Partnering with Remote Area Medical, a global humanitarian organization, 60 organizations came together from across the state of Washington to provide free healthcare. By the end of the weekend, more than 1,500 volunteers had provided $2.4 million of free dental, vision and medical care to 3,386 members of the underserved and vulnerable population of the area, many of whom lined the sidewalks outside KeyArena for days to get access to care.1 It was remarkable to see the floor of the KeyArena— normally reserved for basketball, ice hockey, and concerts—transformed into a massive clinical care environment. The logistics of 60 operatories were remarkably well-planned and well-executed, allowing us to support the delivery of a full range of dental services, from restorative care to imaging, root canal therapy, fabrication of immediate dentures, and tooth extractions. The event also staged more than 40 medical examination ‘ rooms’’ and performed eye examinations, producing 300 sets of prescription glasses each day. Although awkward at first, within seeing my first couple of patients, I was well-acclimated to delivering oral surgery services in the makeshift, transient environment. I am glad I thought to bring my own headlight. The patients proved to be quite remarkable, despite their current adverse circumstances. One patient I met had a very unusual accent. To my ear it was not English, Scottish, or Australian, but a unique combination of them all. While waiting for the local anesthesia to take effect, she filled me in on her background. She was born in Java in the early 1930s, then a Dutch colony located in the East Indies. Her parents were English. In 1942, the Japanese invaded and overran the island. The family was separated and placed in
different prison camps. Only she and her sister survived the war. After liberating the prison camps, the Australian authorities sent the girls to live with foster families, first in Australia and finally in Scotland. Her accent, it turns out, was a composite artifact of these life experiences. Among my pool of patients that day I saw a few who possessed multiple degrees from well-known universities, former small business owners, mechanics, day laborers, artists, musicians, and grandmothers of countless grandchildren. Such was the fabric of this patient population, marginalized on the outskirts of our community, but each possessing a unique story to tell. Their mouths were a direct reflection of the hard times they had experienced. The demographics of the patients we saw were not surprising. Most came to the clinic from the central Puget Sound region. Some, however, had travelled several hours from eastern Washington to reach the clinic. Forty percent of all the registered patients were unemployed. In addition, based on sample data from the patient survey, almost 75% of patients had incomes less than 200% of the Federal Poverty Level. More than one half of all registered patients reported that it had been more than 1 year since their last medical care visit. For greater than 70% of the patients, it had been more than 1 year since their last visit to a dentist. In the survey sample, only one third of the patients reported having any form of medical insurance, and fewer than 10% had dental insurance. There was great comradery among the volunteers, eventually reaching a level of coordination that I love to see on a daily basis in my own clinic. At the end of a long day, we were beyond tired, but felt good about the event and the services we were able to provide. Despite our self-congratulations, however, one question kept nagging at me: had we moved the ‘‘needle’’ on the healthcare needs of King County’s underserved? Notwithstanding this huge logistic adventure in mobile healthcare, I believe the simple answer is ‘‘no.’’ Although both noble and notable, a 1-time, 1-shot effort—even if we continue, as planned, to do this on an annual basis—is an insufficient response to the unmet healthcare needs of this community. Treating the uninsured and underinsured in our community is more controversial than it should be. The vast majority of dentists volunteering their services at our community event were from private practices. However, many of these same clinicians
1237
1238 will not provide services to Medicaid recipients in their own practices. I understand the reason for refusing to accept Medicaid patients. Dental services, particularly in Washington, are grossly undercompensated. It is a challenge even for those of us in academic centers to absorb the underinsured. I cannot help wondering, however, whether we owe society for the privilege of remaining selfregulated. Do we have a professional or moral obligation to absorb the care for those who require services that only we provide? I am not suggesting that we throw open our doors at the expense of fiscal responsibility. However, is not facilitating access to dental and oral and maxillofacial surgical services something for which we are jointly accountable as professionals? Does not regulation tend to occur where groups cannot balance the supply and demand of essential services? If so, perhaps caring for the underinsured is a challenge we should address collectively. How much effect could we have if we all committed a portion of our clinical service (<5%) to caring for the underserved and underinsured in our communities? Academic teaching centers and dental schools are
EDITORIAL
facing greater and greater fiscal challenges, crumbling under the burden of providing a disproportional share of care to the underinsured. Should we consider social obligation the price we pay for self-regulation? Every day I read about clinicians in our specialty and others who provide volunteer care in third world nations. They are the heroes among us. However, it does not take a passport and a series of shots to find people in dire need of healthcare services. Unfortunately, too many can be found in our own backyards. THOMAS B. DODSON, DMD, MPH Associate Editor
Reference 1. Seattle/King County Clinic. October 23-26, 2014. Final Report. Available at: http://seattlecenter.org.media/SKC-Clinic-2014-FinalReport.pdf. Accessed May 18, 2015
Ó 2015 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons http://dx.doi.org/10.1016/j.joms.2015.04.021