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Developing an Ethic of Access to Care in Dentistry

Key words: dental education, ethics, professionalism, integrity

	Abstract

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The ethical responsibility to provide access to care as part of professionalism is explored. Several suggestions for positioning dental education to enhance the public service side of professionalism are presented prior to admission to dental school, during dental school, and after dental school. All three areas hold possibilities for dental education to instill and advocate for the public service aspect of professionalism.

A number of medical groups have recently focused on how to recapture the essence of such professionalism in health care. The Institute of Medicine has produced two reports,^2,3 and a project by a consortium of internal medicine groups has published a document titled "Medical Professionalism in the New Millennium: A Physician Charter."⁴ The authors hope that everyone "involved in health care" will use the charter to engage in discussions to strengthen the ethical underpinning of professional relationships. The Physician Charter sets out three fundamental principles that are not new but reinforce the foundation of the medical profession as one of service to others. The ethical principles of the primacy of patient welfare (beneficence and nonmaleficence) and patient autonomy are listed first, and the principle of social justice is the third main tenet. Clearly, the goal is to reinvigorate the value of a professionalism that includes social responsibility: the ethic of care, and access to that care, for all members of society.

Professionalism is rooted in a relationship or contract with society. Ministry, medicine, and law grew from medieval guilds that were established in universities. Entrance into these fields was controlled through the awarding of educational credentials. Early dental practitioners were itinerant barbers, and the road to professional status moved from apprenticeship to education through the establishment of professional schools.⁵ Developing an educational process gave the members control over entry into the occupation and the size of the labor force. Because of the smaller number and their education, professionals became trustees of the community and took leadership positions in their societies.⁶ This led to the public understanding that the professional person’s knowledge is linked with service in the interest of the local community. Ultimately, the professional came to be defined as someone learned, publicly licensed, and supported by a collegial organization of peers committed to an ethic of service to clients and the public.⁷ The professions then are much like universities in this sense: given a unique charter that grants autonomy and special status for a public purpose.

Over time, there has been a general disaffection and skepticism with the professions and a tarnishing of the general esteem once held by the public. Today, health care providers may readily list the rights and responsibilities that they accept as part of their privileged status in society. Yet what is often missing is the ethical commitment to access to care. There has been an erosion of social consciousness in our professionalism. We must consider how a dental education may instill a sense of public purpose in our graduates. Medical school programs are trying to accomplish this with a renewed focus on the idealism inherent in the mission of medicine.^8,9 One school has recently dedicated a center to preserve the "altruism, idealism, and patient-centeredness" that students enter with but that erode during the training years.¹⁰ This center’s programs will promote communication, ethics, and accountability for professionals to address attitudes and behavior towards health disparities and health access.

Graham in his article suggested targeting three areas for positioning dental education to enhance the public service side of professionalism: 1) prior to admission to dental school, 2) during dental school, and 3) after dental school.¹¹ All three stages hold possibilities for dental educators to instill and advocate for the public service aspect of professionalism. I would like to comment on some of these suggestions.

	Prior to Admission to Dental School

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In an ideal world, dental school admissions committees would admit only those individuals who have an altruistic predisposition toward service: those who are motivated by more than just the autonomy and financial rewards found in dentistry. How do we seek out those more inclined to perform public service? Perhaps dental schools may rank volunteer work like working in a community health center or mobile dental van as part of the acceptance criteria. High school and undergraduate college students often look for opportunities to experience different fields as they determine their career path. A dental clinic serving certain target groups or a rural community clinic would be an ideal learning laboratory for those with an interest in the dental fields and might encourage a desire to work in a community dental health center as an employee or volunteer. For dental schools that are already considering volunteer service history as part of the admissions criteria, they might also consider increasing the emphasis or percentage of credit given to community-minded activities. Increasing the number of underrepresented minorities (URM) will hopefully result in more of these graduates returning to their communities to provide dental care. This is one strategy that holds promise but cannot solve the maldistribution or all of the gaps in patients’ access to dental care because so few practitioners are focused on finding a way to meet the needs of underserved communities.

Dental schools state in their mission and goals the desire to train and educate competent professionals who exhibit professional traits such as empathy, compassion, and respect. An emphasis on the social contract that we have with society must be acknowledged in our mission statements and when we outline our educational goals. All literature and verbal communication should reflect this, from our recruiting brochures to our classroom lectures to our administrative focus; all members of the academic enterprise should share this vision as they impart the desire for clinical excellence. Perhaps there are other media approaches that would also carry this message in an effective manner.

Prior to the start of dental school, should we be cultivating an "introspective orientation to professional life" as Bertolami¹² advocated? His premise of developing a precurriculum between acceptance and matriculation when students are fundamentally idealistic has merit and is worth pursuing. Values clarification is an excellent vehicle to start a discussion on ethics and self-awareness. A tool that is gaining greater application in higher education is the written portfolio. These are journals of professional experience and practice that document individual progress, learning, and reflection. The use of a portfolio to document professional development and self-directed learning is recognized as a valid instrument for evaluating and documenting learning in medical education and by the Accreditation Council for Graduate Medical Education.¹³ Adapting such a mechanism could allow educators to monitor the learning process and professional assimilation as a dental student moves through the preclinical to clinical years.

	Training in Dental Schools

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The Commission on Dental Accreditation requires content in ethical reasoning and professional responsibility.¹⁴ A survey published in 2000 stated that 91 percent of dental schools offer a course in dental ethics.¹⁵ Awareness of ethical issues in dentistry and the use of an ethical decision making model are taught in most dental programs. What must also be emphasized are social justice issues and the uniqueness of various dental care delivery systems such as Medicare and Medicaid. Introducing the problems identified in the surgeon general’s report on oral health can help students and faculty grapple with the realities of oral health care discrepancies.¹⁶ More discussion and understanding around the professional contract that dentistry has with society in didactic and clinical courses might help sustain that message throughout the dental education program. Dental public health courses usually address health policy and advocacy for oral health issues such as fluoridation. Exposure to stronger and more diverse attitudes and perceptions, perhaps outside the dental school walls, may also provide an avenue to heighten an interest in state or national health politics and policies. We need advocacy for oral care policies in many arenas, and students must be engaged with the issues so that they may become successful advocates. Offering dental students electives with medical students or public health students could be one way to increase exposure to larger health care policy for the interested student, but we would have to consider how a schedule might accommodate such electives in an already demanding and time-intensive dental curriculum. Additional measures or benchmarks will need to be established to monitor our success or failure in any of these approaches.

Another facet of our predoctoral programs that we could examine is the grading practices in the comprehensive clinics when students are applying and refining their clinical skills, traditionally in the last two years of dental school. Students should be evaluated for exhibiting traits such as caring and compassion in the clinical setting, along with displaying competency in technical procedures. Clinical faculty members are mentors who have a powerful influence on students. These faculty members have many "teachable moments" on a day-to-day basis, where the ethical obligations that are part of the acceptance of a professional degree may be reinforced and modeled. Similarly, if clinical faculty observe inappropriate or unethical actions such as breaches in confidentiality or selecting certain types of patients over others, the teachable opportunity exists to open a critical discussion with the student and to continually refer that discussion back to the ethical obligations of a health care professional. Are these things addressed or ignored? Faculty must acknowledge the students who excel in demonstrating ideal care provider traits. It is also our obligation to challenge the students who demonstrate ethically perilous behaviors and attitudes.

Students who are given honors and awards at graduation are shining examples of what the professional dental health provider should be from all views of the educational experience. Honor students are well attuned to what counts towards a grade and eventually to graduation. We must then offer a curriculum that awards points or credit for the student who travels to a foreign country on a dental mission or the student who leaves clinic to volunteer in a dental mobile van or other such activity. Awarding credit is a powerful tool and underscores a message of importance. In law schools, the expectation for pro bono service is stated, reinforced throughout the curriculum, and in some states, mandated for each member of the bar. Many undergraduate colleges are now doing this, and some medical schools are following suit. We may instill this ethic by requiring a certain number of community service hours over the four years of dental school.

The number of extramural clinical rotations for predoctoral dental students has grown in the last few years. The annual ADEA senior survey results indicate that dental students’ extramural experience positively affected their ability to provide care to racially and ethnically diverse groups. This same survey also reported that 77 percent of the group agreed that access to oral health care was a "societal good and right" and 81 percent agreed that ensuring and providing care to all segments of society is an ethical and professional obligation.¹⁷ This is good news and gives reassurance that exposure to populations not seen in the general dental school clinics will result in a willingness to treat these underserved URM populations after graduation.

Faculty role models who demonstrate a commitment to service can influence students’ outlook on their profession. Clinical faculty may assume a lead role in organizing volunteer activities. Dental schools should support the faculty in material and other ways such as publicizing and recruiting students. Give Kids A Smile (GKAS) is a great example of a public service event usually based in dental schools and aimed at helping those children who do not have other means of receiving care. But this is an annual day of service that may be staffed only by pediatric dentistry departments. There is also Senior Smile or similar programs aimed at providing oral health care for senior citizens who have very limited incomes and no dental insurance. Someone at the dental school may further explore the array of volunteer opportunities: health programs for migrant workers, HIV-positive persons, the homeless, family violence victims, workers in transition, and other disenfranchised groups. Schools may publish profiles of faculty members who participate in such endeavors as mobile dental vans, rural medical teams, or church and fraternal organizations who do missions in the United States and abroad. Our students will remember that what we do speaks volumes over what we say should be done.

The American Dental Education Association (ADEA) position paper that addresses improving the oral health status of all Americans stresses that academic dental institutions are the fundamental underpinning of the nation’s oral health.¹⁸ Understanding and accepting this role demands that we teach and exhibit values that prepare students to commit to delivering oral health care to all populations. This message should be part of our teaching mission and carried out in words and actions. This is not easy to do in today’s resource-challenged educational environment, but is critically important to maintaining our professional role.

	After Graduation from Dental School

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The Principles of Ethics and Code of Professional Conduct for dentistry are reviewed and housed by the American Dental Association. This code is a principle-based code that includes justice. A description of the justice principle instructs the members to "actively seek allies throughout society on specific activities that will help improve access to care for all."¹⁹ The code goes on to provide guidance on patient selection, patients with bloodborne pathogens, emergency service, justifiable criticism, expert testimony, and fees. No social justice discussion or further advisement on improving access to care is provided except for the mention of the quality of charity in the preamble. This contrasts starkly with the American Medical Association’s code of ethics, which provides a thoughtful discussion regarding society’s obligation to ensure adequate health care to all, regardless of ability to pay and of the physician’s role in working to achieve that goal.²⁰ The profession of dentistry needs to examine and enhance the social consciousness aspect in the code, our contract with society. We should review and clarify our role in improving the oral health status of all Americans.

One approach would be to initiate dialogue with the people we serve, not just other dentists or health care providers. This may call for a look at the relationship of the dental profession to society. We are aware that all citizens have the ability to comment upon the ethics that govern the relationship between the professional and society. These citizens can also participate in a dialogue that would result in an understanding among the members—a look at the social contract among the dental profession and the public we serve. Robert Veatch advocated this course of action over twenty years ago as he wrote about the shift toward a more interactive and reciprocal relationship between the profession and lay people.²¹ Ozar and Sokol articulated this idea again in both of their editions of Dental Ethics at Chairside.²² The dental profession by its very nature is a social enterprise, and its norms are the product of an ongoing dialogue between dentists and the larger community. It is time that we ask the lay public to be an active participant in the articulation of the norms of the dental public-professional relationship.

We must consider our obligations as a group, and not just as individuals who are members of a group. Jong warned in 1988 that "professions exist only at the pleasure of society; if professionals fail to promote the good of society, they will cease to exist because society can regulate and thus limit the autonomy of professions at will."²³ Our responsibility to promote the good of the greater society needs to be cherished because it is an essential part of being a professional group. It is worth cultivating in dental education because it is the right thing to do. Our existence and society’s welfare depend upon us honoring our ethical obligations as professionals.

	Acknowledgments

 
The author thanks Dr. Gary Chiodo and Dr. Denice Stewart for their advice and comments on this manuscript.

	Footnotes

 
Dr. Beemsterboer is Associate Dean for Academic Affairs, School of Dentistry, Oregon Health & Science University. Direct correspondence and requests for reprints to her at School of Dentistry, Oregon Health & Science University, 611 SW Campus Drive, Portland, OR 97239; 503-494-8801 phone; beemster{at}ohsu.edu.

	REFERENCES

Top Abstract Prior to admission to... Training in dental schools After graduation from dental... References

 

1. Oregon Health & Science University, Portland, Oregon. Commencement ceremonies, 2005 and 2006.
2. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21^st century. Washington, DC: National Academy Press, 2001.
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4. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136(3):36–47.
5. Ring ME. Dentistry: an illustrated history. New York: H. Abrams Publisher, 1992.
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10. John Benson Center on Professionalism, Oregon Health & Science University. At: www.ohsu.edu/ethics. Accessed: July 19, 2005.
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16. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
17. Weaver RG, Chmar JE, Haden NK, Valachovic RW. Annual ADEA survey of dental school seniors: 2004 graduating class. J Dent Educ 2005; 69:595–619.[Free Full Text]
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