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Critical Issues in Dental Education |
Key words: dentists, dental education, Latino, dentist supply, language, practice location, California
Submitted for publication 01/12/06; accepted 10/02/06
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Abstract |
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In 1996, the American Dental Education Association (ADEA) revised its bylaws to include core values. Core value 5 states: "Expanding the Diversity of Dental Education. The Association values diversity and believes that those who populate dental education—students, faculty, staff, administrators, and patients—should reflect the diversity of our society."2
Dentists have traveled through an educational pipeline3 beginning in elementary school and culminating in dental school. Different ethnic groups have different experiences with this educational pipeline. This research project was undertaken to see how demographic dynamics within the profession of dentistry in California compare with that state’s new demographics. The effects of the ethnic composition of the state’s dentist supply on some aspect of the quality of care will then be analyzed, along with some suggestions for dental education.
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Methods |
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Data on language were taken from the 2000 U.S. census Public Use Microdata Samples (PUMS), which provide detailed information on the occupation and language abilities of individuals.
This study identified Latino dentists by applying a Latino-characteristic algorithm, developed by the Center for the Study of Latino Health and Culture (CESLAC) at the University of California, Los Angeles, to the CDCA listing of 25,273 dentists licensed in 2000. This algorithm uses surrogate measures of ethnicity: country of graduation and possession of a Spanish surname.
Experience from researching other Latino health professionals4 led us to suspect that we would identify a relatively large number of Latino dentists trained in schools of dentistry outside the United States. Our first step in identifying Latino dentists was to distinguish between graduates of U.S. schools and those of schools in Latin America, which are defined as being located in the Spanish-speaking countries in the western hemisphere. To be consistent with the Latin American Dental Association’s membership, we included schools in Brazil and Spain. Graduates of these schools were considered to be Latino. Graduates of dental schools in the Philippines were excluded, as these graduates generally do not speak Spanish. From the CDCA listing, we identified 470 international dental graduates from Latin American schools of dentistry.
Until the 1980 census, Latinos were identified in large data sets by use of the "Spanish surname" method. The Bureau of the Census has developed a list of 12,215 surnames that are "heavily Hispanic,"5 which have been shown to correlate very closely with Latino ethnicity. This list was applied to the CDCA listing of graduates of schools of dentistry in the United States, which resulted in the identification of 691 U.S.-educated Latinos with "heavily Hispanic" surnames. The Spanish surname criterion was not applied to graduates of Latin American dental schools.
The major limitation of using the CDCA listing of licensed dentists is that an active license does not necessarily represent dentists in active practice since an unknown number of older dentists like to keep their licenses active even though they are not in full-time practice. In addition, younger dentists may be involved in full-time teaching, research, or administration and hence not be in full-time active practice. We have no way of identifying those not in full-time practice; hence, we probably overestimate, to an unknown degree, the number of dentists actually available to the public seeking care.
The "Spanish surname" method of identifying Latino dentists by surrogate measures has both limitations and strengths. The two major limitations probably lead to a small undercount of Latino dentists. The first is that not all Latinos have Spanish surnames. Females, in particular, may have married non-Latinos and as a result may not bear a Spanish surname. The second is that a number of surnames are used by persons of more than one romance language-speaking country such as Italy, France, Portugal, and even Romania. The U.S. census considers these shared surnames to be "moderately Hispanic" or even "occasionally Hispanic." We excluded these "moderately" and "occasionally" Hispanic surnames from our analysis.
The strength of this method is that it is a rapid, low-cost method of identifying around 90 percent of Latino dentists.5 Absent a survey of all 25,273 dentists, with at least a 93 percent response rate, which was not possible due to budget limitations, the Spanish surname surrogate method provides a good starting point, albeit with limitations that we consider to be acceptable because of the absence of any other research on this topic.
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Results |
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Current Supply
When we applied the Latino-identifying method described above to the CDCA list of 25,273 dentists licensed to practice in California, 1,161 met the criteria. For the remainder of this article, these 1,161 dentists will be considered the universe of Latino dentists in the state, while the remainder of the CDCA dentists will be our non-Latino dentist supply.
These Latino dentists comprised 4.6 percent of the total dentist supply in California in 2000. At the same time, California’s nearly 11 million Latinos (10,966,556 as counted by the 2000 census) comprised almost one-third of the state’s population (32.4 percent). While one out of every three Californians is Latino, only one out of every twenty California dentists is Latino. Clearly, Latinos are not represented in the state’s supply of dentists in proportion to Latino representation in the state’s population.
Source of Latino Dentists
The 1,161 Latino dentists in the state have a markedly different profile in terms of their educational experience compared to non-Latino dentists. In the California non-Latino dentist supply, international dental graduates (IDGs) are rare; only 14.9 percent were graduates educated outside the United States. The major sending countries were the Philippines, India, Taiwan, and Iran. See Table 1
for the top ten countries and their percentages of representation in the state’s non-Latino dentist supply. By contrast, the California Latino dentist supply is heavily dependent upon IDGs. Close to half (40.5 percent) of Latino dentists were educated in Latin American countries. The top sending countries were Mexico, Brazil, and Colombia.
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for the top ten states and their representations.
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indicates the ten schools that have produced the highest number of Latino dentists with California licenses.
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The Decline of the Latino Dentist Supply
Figure 1 shows the growth and shrinkage curves from 1943 to 1999 for each source of Latino dentists: California-educated, out-of-state-educated, and IDG. The year indicates the year of graduation from dental school, not the year that the dentist began to practice in California.
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Prior to 1973, due to the extremely small number of Latino dentistry graduates overall, out-of-state schools were an important factor in producing the supply of Latino dentists during that period. After that date, out-of-state schools became less important, as California schools ramped up their production. Only twice in the entire fifty-six-year period under analysis have out-of-state schools produced more than five graduates who ultimately entered dental practice in California. From the high point in 1991 (eight Latino graduates), the number of out-of-state graduates entering the pipeline to practice in California has fallen by 88 percent.
In the past, schools of dentistry in Mexico and Latin America have been an important source of Latino dentists. In the 1943 to 1985 period, these nations produced almost as many Latino graduates as the California schools. In fact, between 1979 and 1985, they produced more Latino dentists than the California schools, including forty-three Latino graduates from Mexico and Latin America in 1982 alone. Since then, however, the number of IDGs has fallen precipitously. Indeed, from its 1982 high to its 1999 low of zero (none) Latino graduates, the IDG element in the Latino dentist pipeline has fallen 100 percent.
The sharp drop in Latino dentist graduates during the 1980–2000 period (-59 percent for California-educated, -88 percent for out of state, and -100 percent for the IDG graduates) contrasts sharply with the Latino population growth rate of 148 percent (from 4.4 million to 10.9 million) in California over that same period.
The non-Latino dentist supply into the California educational pipeline presents a different dynamic. The number of California-educated non-Latino graduates who chose to practice in the state has remained virtually steady since the early 1970s, around 400 per year. From the early 1960s to 1990, the number of out-of-state, non-Latino graduates remained fairly constant, at around 150 graduates per year. Since 1990, the number of out-of-state graduates has dropped by about one-third. The non-Latino IDG element, while not as important to the overall non-Latino dentist supply, also has fallen off since 1985, virtually to zero.
Latino Dentist Characteristics
The Spanish language has been spoken by significant portions of the population in California since 1769, in an unbroken linguistic presence lasting more than 230 years.6 In the 2000 census, nearly 52 percent of Latino adults (age eighteen to sixty-four) spoke English only or spoke Spanish and English at a level of proficiency "very well." These Latinos most likely would not require Spanish-fluent dentists. However, nearly 48 percent of Latino adults have some difficulty speaking English, at levels of proficiency "not at all," "not well," or only "well." These adults most likely would require Spanish-speaking dentists.
The California dental license does not provide information about a dentist’s language ability; however, a different data set provides this information: the 2000 U.S. census Public Use Microdata Samples (PUMS), which provide detailed data about the language profiles of both non-Latino and Latino dentists in the state. Analysis of this data source reveals that less than 2 percent of non-Latino dentists reported speaking Spanish (1.4 percent), while over two-thirds of Latino dentists spoke Spanish (69.5 percent).7
Another key element in the quality of care is geographic accessibility. The dental license provides information to evaluate the geographic accessibility of a dentist. Each dental license is sent to an address; this address may, or may not, be the office location. Absent any further information, however, we used the zip code of the license address as a proxy measure for practice location.
Using the 2000 PUMS data, all zip codes in Los Angeles County were grouped into three Latino-related categories: low Latino (less than 20 percent Latino population), medium Latino (20–39 percent Latino population), and high Latino (40 percent+ Latino population). The license address was matched to these zip codes. This analysis showed that Latino dentists were more than twice as likely to have a license address in a high Latino zip code, compared to non-Latino U.S. dental graduates. See Table 4 for a detailed breakdown.
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Discussion |
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While Latino representation in the state’s supply of dentists is disproportionately small compared to Latino representation in the state’s overall population, this disproportion will most likely become even worse under current conditions. In brief, the pipeline supplying Latino dentists to the state has virtually dried up, while the Latino population is increasing.
The supply of Latino dentists in California is not simply an affirmative action issue; it is one of access to care. The supply of Latino dentists in California offers two important characteristics that directly affect the quality of care offered to Latino populations: the ability to speak Spanish and a marked tendency to practice in heavily Latino areas. As Latino dentists are far more likely to speak Spanish and to practice in a heavily Latino area, their underrepresentation in the supply of dentists makes it more difficult for Spanish speakers living in heavily Latino areas to find a dentist who is linguistically and geographically accessible.
The ratio of population to dentists yields another way to appreciate this underrepresentation. In the non-Latino population, for every non-Latino dentist, there are 950 non-Latino persons. By stark contrast, in the Latino population, for every Latino dentist there are 9,446 Latino persons.
The underrepresentation of Latino dentists can be quantified. If Latinos had been proportionately represented in the dentist supply—that is, if there were one Latino dentist for every 950 Latinos—there should have been 11,544 Latino dentists licensed to practice in 2000. As we were able to identify only 1,161, this means that there was a Latino dentist shortage of 10,383 Latino dentists in California. In 1996, the U.S. Health Resources and Service Administration, Bureau of Health Professions, reported a national dentist-to-population ratio of 1:5,400 for Hispanics. This data indicates a shortage of more than 5,000 Latino dentists, which is still a significant shortfall and definitely problematic.
If the ADEA goal of Core Value 5 were to be achieved in California, so that the state’s diversity, especially the large and still rapidly growing Latino portion, were reflected in those who populate dental education, then the quality of care available to nearly one-third of the state’s residents would be greatly enhanced. This would be accomplished by an increased Spanish language ability in the provider supply and a greater geographic accessibility as more dentists would choose to practice in heavily Latino areas.
The Latino dentist shortage is critical and getting worse. While the Latino population is projected to grow rapidly, the number of Latino dentists entering the pipeline to practice in the state is shrinking. Steps need to be taken immediately, for the short term and the long term.
Increase supply of Latino USDGs.
The first step is to increase the number of Latino USDGs. As most of these historically have come from California schools, the emphasis needs to be on them. It appears that, at one point, the state’s schools were able to increase dramatically the number of Latino dental students. From 1970 to 1980, Latino graduates entering the pipeline grew eightfold, from four to thirty-three. Clearly, dental schools have the capacity to increase Latino enrollments. The pool from which dental students may be recruited and selected has grown enormously. Between 1990 and 2000, not only did the Latino population grow by 42.7 percent (from 7.7 million to 10 million), but the pool of educated Latinos grew even more rapidly. The number of high school graduates grew by 62.4 percent, and the number of Latinos with graduate and/or professional degrees grew by 60.9 percent.7 With a growing population of highly educated Latinos, it would seem logical to expect to see a concomitant increase in Latino dental students.
Instead, the dramatic drop in Latino graduates entering the pipeline indicates that dental school efforts and activities are badly out of synch with the state’s population changes. A review of the recruitment and admissions procedures employed in the 1970s and 1980s could provide valuable insight about how to increase the number of Latino enrollments quickly.
Increase cultural competence of non-Latino dentists.
The Latino dentist shortage is so large—10,383 for the year 2000—that even dramatic increases in Latino enrollments will not be sufficient to make up the shortfall. A parallel effort will have to be made to increase the cultural competency of non-Latino dentists, so as to create greater access to services for Latino patients. Latino providers in closely related fields have shared the opinion that cultural competency is a learned set of skills and attitudes, potentially available to anyone who invests the time to master them. A recent book, Healing Latinos: Fantasia y Realidad,8 was written by a variety of Latino providers (although unfortunately, no Latino dentists participated) to share with their non-Latino colleagues how they go about providing culturally competent care to their Latino patients.
Cultural competency is also seen in structural issues, such as location of practice and acceptance of Medi-Cal. These can be addressed by programs of incentives and rewards to induce more dentists to locate in heavily Latino areas and work with the insurance profile encountered there.
Increase supply of Latino IDGs.
An immediate, albeit controversial, short-term solution was recently proposed by the California state legislature: the chair of the powerful Latino Caucus in the State Assembly (Marco Firebaugh) introduced a bill, AB 1045,9 to fast-track the immigration of a limited number of dentists and physicians educated in Mexico to practice in extreme shortage areas in rural California. Approved by the governor of California on September 30, 2002, the law has created the Licensed Physicians and Dentists from Mexico Pilot Program. The law allows thirty licensed dentists from Mexico to practice dentistry in California for a period not to exceed three years. Dentists from Mexico eligible to participate in this program need, among other requirements, to be graduates of the National Autonomous University of Mexico School of Faculty Dentistry and to complete an orientation program taught by an instructor affiliated with a California dental school. The law authorizes a three-year nonrenewable dental permit for participating dentists and would prohibit these licenses from being used as the standard for issuing a license to practice dentistry in the state on a permanent basis. The 2003–04 budget crisis in California stopped implementation of the law, but it remains on the books. If organized dental groups do not provide options for the legislature, it would not be surprising if more such measures were introduced.
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Conclusion |
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Footnotes |
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REFERENCES |
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This article has been cited by other articles:
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  P. L. Davidson, D. C. Carreon, S. E. Baumeister, T. T. Nakazono, J. J. Gutierrez, A. A. Afifi, and R. M. Andersen Influence of Contextual Environment and Community-Based Dental Education on Practice Plans of Graduating Seniors J Dent Educ., March 1, 2007; 71(3): 403 - 418. [Abstract] [Full Text] [PDF]
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