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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: public health professional education, ethics consultation, personnel delegation
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Abstract |
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Issues Raised at the Workshop |
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Education is an ethical tool. Various levels of relationships exist between ethics and education. There are ethical questions raised within the educational environment, including content related to knowledge of ethics and decision making skills. Additionally, the role of ethics in determining the central mission of the educational institution and how the faculty, staff, and students contribute to that aspect of the mission is important. To address the teaching and learning focus, specific strategies are suggested. The strategies include assessing current educational tools, sharing them with others, collaborating with dental societies to link students with groups addressing the access to care issues, refocusing education toward learning outcomes, and enhancing ethics and professionalism curricula to include the ethics of access and community-based issues. The goal is to develop dental professionals who, following graduation and throughout their careers, are dedicated to promoting universal access to care.
The role of faculty was also cited as critical to change. Faculty can serve as role models, demonstrating values focusing on service to the public. Clinical faculty, because of their consistent interaction with students, should be oriented to the concepts of a professional obligation to provide care.
It was noted that the Robert Wood Johnson Pipeline Project is an important project that will provide information about the effectiveness of student-based care in community settings. In addition to the model offered by the Pipeline Project, requiring senior dental students to provide care in community-based settings and strategies for involving students earlier in the educational process were proposed. The first and second years of dental school should include community-based education and reflective learning to develop the values and skills necessary for forming an ethic of universal oral health access. Participants were reminded that ADEA is currently involved in a curriculum evaluation and innovation project. It was suggested that the conveners of this workshop contact ADEA with their recommendations for curriculum strategies to better prepare future practitioners to address access to care issues, both during their education and throughout their professional careers. Dental hygiene curriculum guidelines are also currently being revised. There was consensus that focusing on the next generation of practitioners may be the solution to success. Changes in educational strategies may assist in creating a practitioner with the commitment and skills necessary to contribute to the access issue. However, current practitioners can and should have a role as well.
Role of Professional Associations
A portion of the discussion centered on the American Dental Association’s Principles of Ethics and Code of Professional Conduct. It was agreed that the purpose of the workshop and discussion was not to propose a change in the ADA Code, but rather discuss the perspective of the code from both within and outside of the profession. Because codes of ethics have aspirational value, as well as educational and sanctioning values, how codes articulate access to care issues has strong, subtle influences on professional strategies. Participants were also reminded of Ethical Moments in the Journal of the American Dental Association and the ADA Success Program as sources of ethical discussion that broaden and open the ongoing dialogue within the ADA Council of Ethics, Bylaws, and Judicial Affairs. These two relatively recent ADA initiatives could be resources to allow the discussion of access and the role of practitioners in addressing the issue.
It was also pointed out that the American College of Dentists’ code states that it is important to "extend benefits (of care) to all." It is recognized that this discussion has political components and that the leadership of the American Society for Dental Ethics (ASDE), American Dental Association (ADA), American Dental Hygienists’ Association (ADHA), and American College of Dentists (ACD) should link together as a "community" to work on strategies to best educate and motivate practitioners. These organizations have the power to move the agenda forward, and representatives from the workshop may be able to influence that movement.
Practitioners
The important role of practitioners was discussed on various levels. Dental practitioners, either through their local societies or individually, could build networks and coalitions with community advocates and other health care providers to best address local needs. Strategies are necessary to help dentists who are already committed to addressing access to care issues, to increase their awareness of each other and of available resources. Dental hygiene has developed models that address access to care issues. Individuals interested in affecting access issues may want to evaluate the strategies and successes of dental hygienists.
Practitioners could be advised to develop business plans that include providing care to the under-served, which could increase the base of individuals providing care. This could be incorporated into practice management strategies currently presented in dental schools and continuing education programs. Participants pointed to indications that practitioners are interested in addressing access issues, as shown by polls of state dental societies identifying access as one of the top three concerns of members. Based on this finding, "tools of support" could be identified to assist those not currently engaged to better understand the issues and learn about ways to contribute. In addition, there was discussion about the ethic and practice of Universal Patient Acceptance (UPA) as key to systematizing any collaborative strategies. It was agreed that this concept should continue to be evaluated and advocated.
Collaboration and Networking
The need to collaborate on various levels was emphasized as a common theme in the discussions. The participants recognized that dentistry and dental hygiene cannot do it alone and must collaborate with other primary care providers as an interdisciplinary team. Groups interested in oral health disparities are natural partners in addressing the issues.
Participants suggested that "thinking out of the box" was necessary in identifying key groups or organizations that can assist in moving goals and objectives forward. For example, focusing on children and elderly citizens may be a good tactic. Thus, partnering with groups such as the American Association of Retired Persons (AARP) or the Children’s Defense League may be nontraditional strategies that could contribute to successful outcomes. Participants also recommended linking with like-minded organizations, whether philanthropic groups, local, state, and federal agencies, or health-related organizations.
Information Sharing and Resources
All participants agreed that there have been and continue to be excellent publications and reports that identify issues, provide data, and indicate possible solutions. A list was not developed, but participants reminded each other of the breadth and scope of recent publications including the U.S. surgeon general’s report, Sullivan Commission report, Call to Action, and the ADEA President’s Commission on Access report. Suggestions included developing a "document" repository source, thus allowing the information to be distributed to a wider audience. It was also suggested that, for those individuals participating in the workshop, a listserv could be developed to allow information-sharing and strategies among participants to continue the momentum.
Testing and Licensing Agencies and Accrediting Bodies
Participants discussed modifying accreditation standards to be more robust and specific in order to focus dental educational institutions on their obligation to educate future practitioners to be prepared to serve all citizens in their diverse communities. Specific competencies need to be drafted based on this ethical standard. For example, Standard 1 of the Predoctoral Accreditation Standards could be modified to require schools to demonstrate socially responsible care. The current discussions about a national licensing examination could be broadened to focus on access to care.
Research
The participants also recommended creating an evidence base by first developing a research agenda. This research agenda should include national and global perspectives. Currently, there is little funding dedicated to determining the impact of ethics tools and education on health care outcomes or educational outcomes. Unlike medicine, which has growing philanthropic funds and endowed chairs to support educational and organizational ethics efforts, dentistry still relies heavily on volunteer efforts from dedicated individuals as the major source of its ethics scholarship, research, and consultations.
Meeting Outcomes
Participants agreed that a summary of the meeting and outcomes should be reported. This would be useful for participants to use in future professional meetings. A short summary report could be prepared and distributed before the proceedings of the workshop are published as a special issue of the Journal of Dental Education.
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Promises |
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The participants also discussed the need to continue the dialogue on the topic. Gaps were identified, and the implications of access issues were discussed. Future forums should continue the discussion started here. In October 2005, the ACD meeting in Philadelphia, specifically the Leader Skills Presentation, provided a forum to highlight the workshop proceedings. The panelists at the fall ACD meeting briefly discussed the themes of what we know, what we aspire to do, and where the gaps exist as part of their presentations. ACD members were given an opportunity to dialogue following the presentation and offer input about the role of practitioners in addressing the issues. There was also discussion of other forums, including a future ethics summit that may continue the dialogue and strategy development begun at this workshop that could focus more specifically on the impact of commercialization on the mission of professionalism and professional education.
The participants in the workshop agreed that all papers presented at the workshop provided valuable insights and commentary about the issues. Participants indicated they wanted the momentum from the meeting to continue. It was noted that financial support is needed to continue this initiative. However, a number of individuals and organizations voiced a commitment to discuss the ethics of access and continue it on a variety of levels.
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Footnotes |
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