THE EDITOR'S CORNER
Visiting the office of Lyman Wagers and Russell Greer in Lexington, Kentucky (see page 16) was an eye-opener to someone who comes from a state in which expansion of the duties of auxiliary dental personnel is looked upon as encroachment and a threat to the integrity of dental practice. You get the feeling that the dentists in states like Kentucky, while they are not ahead of their time, are ahead of many other states in developing concepts of dental practice which will permit a high level of dental care to be delivered to a much larger segment of the population than heretofore; and that, after all, is the mission of dentistry.
The Kentucky Dental Practice Act has been changed in recent years at the instigation of the dentists in that state, to permit auxiliary personnel to perform a variety of procedures which were formerly reserved for dentists only. For example, in an orthodontic office and under the supervision of the orthodontist, a dental assistant can take x-rays, take impressions for study models, select bands, cement bands, clean off excess cement, select archwires, and tie in archwires. They do not perform duties which involve decision-making about diagnosis and treatment, or the design and adjustment of archwires and appliances.
Kentucky is not alone. There is a growing number of states which are changing or considering changing their dental practice acts to move in the same direction as Kentucky has. Some states are not and some dentists oppose it, but it is a trend that undoubtedly will continue.
If we are, as we seem to be in this country, on the verge of a national health care program, then there will be a greatly expanded number of people who will be seeking dentistry, including orthodontics, under such a program. Picture, if you will, five million orthodontic patients a year, which is a conceivable figure for the potential orthodontic case load under a national health plan. Can they be serviced by five thousand orthodontists? Not under our present practice arrangements. Can the number of orthodontists be increased significantly? It is unlikely that it would be possible or desirable to try to make a great increase in the number of orthodontists in this country. The supply of satisfactory candidates and the availability of personnel and facilities to train them cannot be expected to increase suddenly and significantly. Add to this the fact that there will be an even greater initial need for general dentists with the same problem of supply and training.
What could be done? We could use some index of severity to screen orthodontic patients and treat only the more severe problems. This is hardly a satisfactory public health procedure if you really intend to provide the people with comprehensive health care, assuming that you could make an equitable selection in this way and assuming that there was not a better alternative.
What else could be done? We could develop methods of prevention and improved methods of treatment. We hope to accomplish both of these objectives, but they do not appear to be so close to reality that you would base a program on them.
The only solution to the problem that presently makes sense is to make each orthodontist more productive. The ways that are available to accomplish this include working longer hours, using simpler appliances, setting lesser treatment goals. But, there is only one that should be acceptable to orthodontists and that is to delegate duties to trained auxiliaries. With enough duties delegated, you can begin to visualize the present roster of orthodontists handling the future patient load, delivering a service comparable to present practice.
In the office of Wagers and Greer and in many others around the country, you can see this process unfolding and you can see that it is successful. There are many skilled tasks in orthodontic treatment which require training but not graduate education in order to perform them in a satisfactory manner. There cannot be any question about whether auxiliaries can be trained to perform duties formerly reserved for the graduate orthodontist. They can be and are being trained to perform them proficiently. A number of us orthodontists may just like to do these tasks ourselves, or we mistrust delegation of our responsibility to others, or we disbelieve that auxiliaries can readily be trained to perform these tasks. If so, we are merely being stubborn or ill-informed.
A fringe benefit to the country from the expanded use of dental auxiliaries is that we would be creating new jobs for a society that is increasingly automating people out of former jobs and increasingly educating people away from less skilled employment.
One problem about hiring, training and using more auxiliaries is that you have to be in an area with a ready supply of patients. If you try to hire many more assistants with the same number of patient starts available each year, either you are going to have to raise your fees and not lose many patients in the process, or you are going to lose take-home pay yourself. You will get some of the other benefits of adding personnel.
It is one of the paradoxes of orthodontic practice today that metropolitan areas, which are likely to see the greatest increase in numbers of patients under expanding third party programs, are not the areas in the country which have an overabundance of orthodontic patients now. Therefore, we are not seeing the movement toward expanded use of auxiliaries in these areas. In fact, this is where the opposition is likely to be the greatest. Unless the ball on this important development is going to be carried by practitioners in rural America or in relatively smaller cities, we are going to have to see the rise of many more group practices in metropolitan areas. This may make up by shared expenses for the relative shortage of new patients--to keep expanded numbers of auxiliaries busy.
The picture is entirely different when there is an adequate supply of new patients. Each auxiliary then is able to earn for the practice an amount much larger than his or her salary. The number of patients taken on under an open-ended patient availability in any one office depends on the orthodontist being able to accomplish the duties for the patients which he cannot delegate and for which he is still responsible. Under such conditions, the orthodontist's income must rise or his fees can be reduced or both of these may occur and this is the likeliest development in a program of greatly expanded patient loads and greatly expanded use of auxiliary personnel.
The question of reducing fees may be a sensitive area at first glance. However, it should be one of the objectives of expanded use of auxiliary personnel to anticipate the time when third party programs--government and private--supplying large numbers of orthodontic patients and paying for their care, will be requiring a cost accounting basis for orthodontic fees and fees that make the treatment of possibly ten million orthodontic patients at one time a financial possibility. The ten million figure comes from five million new patients a year for an average treatment time of two years. If you multiply ten million by almost any number the result is very large. If we assume for purposes of example only that an orthodontic fee is $1000 for treatment that averages two years, and you then multiply the ten million by $500, you have a figure of five billion dollars. It is inconceivable that any people will spend five billion dollars a year on orthodontic treatment.
The likelihood is that five billion dollars a year may be spent on all of dentistry and that services such as orthodontics will be increased as general dental services may be decreased by prevention and improved correction. With the programmed expenditure of that kind of money, you can be sure that the dentist and orthodontist will be permitted to remain as individual entrepreneurs only if it can be demonstrated that this is the best format for delivering the service. Time is not on our side. We must quickly explore this avenue of expanded use of auxiliary personnel and so organize the delivery of care that the cost factor will not prevent the program from occurring in the optimum way for the people and the profession.
