A philosophical question: How much medical training is needed to treat patients? Some say it's the full course as proscribed by existing medical, nursing, or dental schools. But when the shortages of doctors, nurses, and dentists are ginormous, does the need require a different answer?
Consider oral health. "Shortages of dental practitioners and affordable dental care are hurting the health of millions of Americans, many of whom live with pain, miss school or work, and, in extreme cases, face life-threatening medical emergencies that result from dental infections. The situation is particularly severe for poor children and families and in communities of color,'ê writes Burton L. Edelstein, DDS, MPH of Columbia University and Children'ês Dental Health Project in a December 2009 report for the W.K. Kellogg Foundation.
And, like most health issues, the data shows that Indian Country is at the low end of the spectrum. One study described it this way: The American Indian/Alaska Native population "has the highest tooth decay rate of any population cohort in the United States: 5 times the US average for children 2'ê4 years of age. Seventy-nine percent of AIAN children, aged 2'ê5 years, have tooth decay, with 60 percent of these children having severe early childhood caries (baby bottle tooth decay). Eighty-seven percent of these children, aged 6'ê14 years, have a history of decay — twice the rate of dental caries experienced by the general population."
The study, by David A. Nash at the University of Kentucky and Ron J. Nagel with the Indian Health Service, found that "lack of access to professional dental care is a significant contributor to the disparities in oral health that exist in the AIAN population. Two major factors contribute to inadequate access to care: the relative geographic isolation of tribal populations, particularly in Alaska; and the inability to attract dentists to practice in IHS or tribal health facilities in rural areas."
So several years ago an experiment began in Alaska to change the training paradigm. The Alaska Native Tribal Health Consortium, working in partnership with the University of Washington, began training Dental Health Aide Therapists. These oral health agents work under the general supervision of a dentist (who is at another location). The dental therapists practice includes basic dental services, focusing on children's needs, including tooth extractions, and sending full reports to their supervising dentist.
The key to the program is that the therapists are trained right out of high school over a two-year program — and then work in the remote villages where it's been nearly impossible to recruit full-time dentists.
"While dental therapy is still relatively new to the United States, past training demonstrations in various states have proven that the care they provide is safe, acceptable to patients, cost-effective, and productive. Unlike earlier efforts, the two most recent dental therapy programs in the U.S. are not just training therapists but sanctioning their placement in underserved communities," writes Edelstein in the Kellogg report.
The National Congress of American Indians Policy Research Center said expanding this program to American Indian communities outside of Alaska would "be a major health breakthrough for Native populations across the country."
The American Dental Association and the Alaska Dental Society challenged the dental therapist program in court. But the case was dropped for a couple of reasons: Alaska Natives were exercising their own authority under the policy of self-determination and it's hard to argue against limited oral health care when personnel shortages meant there was practically no care.
The federal Agency for Healthcare Research and Quality reports that the Alaska dental therapist model is absolutely successful expanding access to oral health: "As of 2009, there are 13 dental therapists serving 42 villages in Alaska, providing year-round services to thousands of Alaskans who previously had access to services only a few weeks a year." While the villages with "a dental therapist these same communities have year-round access to basic safety net services."
Moreover, the report said, "a professor of dentistry from the University of Washington found that the first four dental therapists employed in Alaska met evaluators' standards for record review, cavity preparation and restoration, patient management, and patient safety. He recommended that the program not only continue but be expanded."
Health care reform — not the law itself, but what it means in real world practice — requires a new thinking about how to serve patients across the board. We need to write this generation's definitions of who should do what — dentists, practitioner, hygienists, and therapists. What are the education levels and licensing requirements? What's the right balance for standards? The answers, in most cases will be state by state, with some exceptions in the broader Indian health system.
The new health care reform bill and the Indian Health Care Improvement Act support more experiments with this model, including the possibility of training programs at tribal colleges. A philosophical question answered by meeting the needs of people.