The following article, written in 2000, is about my experiences in the Indian Public Health Service 37 years ago. Today, in light of the turmoil and resistance surrounding the government’s long overdue bid to overhaul the health care delivery system of the United States, this article is timely even today. Even though there have been some positive changes in federal and state funded programs for this and other long-neglected populations that have limited access, I believe that inequality in the delivery of proper dental care still exists.
I have a confession to make. When I was in dental school in the early 1970’s, I had very lofty dreams invisalign. The Vietnam War was winding down, and it was a time of peace and love and caring for your fellow man. As a senior, I researched many possibilities that would allow me to earn a living as a dentist while serving humankind. I felt that I could fulfill those dreams by either working in a dental clinic or operating a mobile dental van in the low-income inner city or rural areas where good dentistry was hard to find. Then I learned about a position that could be the answer to all of my conditions.
When I graduated from Georgetown Dental School in 1973, I chose to enter the Indian Public Health Service. I thought that it was an ideal program in which I could further my education and begin a lifetime of service to my community. I was sent to The Fort Berthhold Indian Reservation 5 miles from Newtown, North Dakota. My family and I were given a three-bedroom house, which was on a compound with ten other homes and a clinic. One physician and several other health professionals including myself, social workers and nurses lived in the other houses. It was wonderful. After all, work was a short walking distance, and we had a full view of the Missouri River from our window and wild horses galloping in the fields among the beautiful Dakota buttes. I was very excited about living in such a beautiful and spiritual land with my family and happy with the prospect of helping people who wouldn’t otherwise receive dental care. More important was the knowledge that I did not have to rely on charging fees for my skill or creating a high volume practice in order to survive. It wasn’t long before my bubble burst and the bureaucracy and prejudice of the system became apparent.
The basics of dental treatment, including examinations, cleanings, fillings and extractions, were offered. Other more costly services which may have been necessary to save teeth such as endodontics (root canal therapy), crown and bridge, partial or full dentures and periodontal (gum and bone) treatment required pre-approval similar to pre-authorizations needed for insurance companies. Children were usually approved for the basics, but treatment for adults, particularly those who needed a combination of root canal treatment with crown and bridge, were rarely approved.
Because of the small population of the reservation (4000) and the limited budget of the program, some physicians and dentists, like myself, were recruited right out of dental school and were placed in a very difficult situation, whereby they found themselves as the sole providers of their specialty of health care in the facility. Inexperienced dentists did not have the benefit of further hands-on education working with others in their profession who possessed more experience, for consultations, or for doing more difficult procedures. Obviously, my skills were limited and my patients were the unfortunate beneficiaries of my learning curve. For the first time, I understood the true meaning of the term, ” to practice dentistry.”
Based on the economics of the system, Indian Public Health often recommended extraction (removal) of teeth and partial or full dentures. The same is true in similar instances where low income patients receiving government sponsored Medicaid benefits or patients with private or employee benefits dental insurance could be refused necessary tooth-saving treatment simply because it would not be cost beneficial to save the teeth. Even though many patients are helped by these programs and may not otherwise be able to afford even basic dental treatment, recommendations based on cost-effectiveness and profit margin is wrong. It often resulted in the removal of marginally damaged teeth. This, along with the unfortunate, but inevitable, mistakes of a rookie dentist, created a cycle of mistrust between this dentist and his patients.
The creation of trust and love between the dentist and the patient is one of the most important elements of the successful relationship within the dental environment. I laugh when I think of how naïve I was. I tried to work around the system by applying for tooth-saving benefits for adults. They were rejected. I wrote articles on dental health and nutrition for the clinic news bulletin. It fell on deaf ears. I tried to teach my patients home care and gave them nutritional advice. Not many cared. I created a children’s dental health week poster contest and gave away solicited prizes such as toothbrushes and floss to the winners. Very few children entered. I went on a local TV show called “Bowling for Dollars” and several radio shows in order to spread the message. It made no impact. It became more frustrating for me as time went by. I realized that years of abuse and neglect by the system wasn’t going to be eliminated by a Jewish white boy from New York. This lack of “love and trust” often showed as very fearful patients, or an excessive number of broken appointments, or great difficulty filling the appointment book. But, the bottom line was that the missing piece was “love and trust.” They didn’t trust me. They didn’t love me.