“I can’t wait to help others!” “I look forward to giving back to my community!” “I have a heart for service.” “Helping those less fortunate is important to me.” “My dental mission trip changed my life — I hope to be able to help others when I’m a dentist.”
Sound familiar? You probably said something like it in your personal statement when applying to dental school. We all volunteered dozens of hours to meet the community service component of the application, and we said we looked forward to making the world a better place after graduation. Yet only 43% of American dentists accept Medicaid or the Children’s Health Insurance Program (CHIP) platforms designed to serve low-income populations in America. Why do the large majority of us begin dental school with the idea that we have an obligation to help these populations, but by the end of our D4 year, only about one-third of us feel that same responsibility?
In a longitudinal study published in the Journal of Dental Education (JDE) in May 2016, researchers followed three classes of dental students through their D1 to D4 years to evaluate their attitudes toward treating underserved populations after graduation. Their positive feelings about treating low-income, elderly, homebound, homeless, other ethnic groups and non-English speaking patients decreased. Yet their positive feelings about treating medically complex patients, drug user and HIV/AIDS patients increased. According to the study, exposure to some populations increased students’ willingness to serve them, but exposure to low-income populations and patients with Medicaid did not.
Another group of researchers in an earlier study explored the relationship between students’ professional/educational experiences with patients on Medicaid and their attitudes and behavior toward treating these patients. Students who had experiences with Medicaid patients before dental school were more likely to treat these patients after graduation than those who didn’t have pre-dental-school encounters. And, according to the study, even though those students (with no prior experience with Medicaid patients) became more comfortable and enjoyed treating Medicaid patients, they were less likely to treat them in the future.
Dr. Jessica Meeske, an adjunct professor at the University of Nebraska and owner/provider of a large pediatric practice with multiple locations in Nebraska, says, “So many dental students become jaded [about being] future providers of children and adults with Medicaid by faculty, personal biases, red tape in their school clinics and hearing from some practicing dentists that it’s not profitable.”
As students grow and mature toward graduation, they are more aware of the financial burdens of dental school loans and family obligations. As students start talking to future employers, they may hear stories of the challenges and mounds of paperwork that come from taking Medicaid. (I informally surveyed six dentists who all cited paperwork as a top reason they don’t take Medicaid, though none of them had actually ever accepted it.)
In addition, dental students are influenced by dental school faculty. As stated in the 2016 study, “Faculty members should be keenly aware of how their own biases, both negative and positive, may influence students’ intent to treat underserved populations.”
As Dr. Melissa Shaw, a pediatric dentist in Watkinsville, Georgia, recounts, “In dental school, I remember some faculty and private practice doctors covering clinic would often make negative comments about Medicaid. [They’d] say, ‘You’ll have to double or triple book your schedule because of the no shows,’ or ‘You’ll want to book Medicaid on a different day, so they don’t give the wrong impression to your private-pay patients when they’re sitting in the waiting room.’ That is all nonsense.”
For Dr. Shaw, “The most important thing is to treat every patient with dignity and respect, no matter who they are. If that is the type of culture you establish in your office, the attitudes and actions of the patients (and parents in our case) will follow.”
Dr. Meeske reiterates this philosophy: “[M]edicaid covers a diverse segment of the population that includes single moms, widower dads, seniors, veterans, grad students, children and persons with special needs. You can’t assume that everyone has the same values, health literacy and resources to get to a dental appointment.”
What can be done to encourage students to become Medicaid providers after graduation? As Dr. Meeske lectures to students at the University of Nebraska, roadblocks “can be overcome with understanding poverty, how to best serve [the underprivileged] and [education on] the Medicaid system.” She suggests dentists educate themselves about the effects of poverty and cultural barriers on health care. Acknowledging that we might not understand someone else’s experience might be hard, but there are resources to help us become more compassionate health care providers.
Dental schools should take a greater role in encouraging students to treat the disadvantaged through Medicaid. Findings from an April 2006 JDE study show that access to oral health care for underserved populations would most likely increase if dental students received direct instruction from their dental schools about the importance of treating all patients. Multiple studies, including one from the January 2014 issue of JDE, show that community-based clinical programs are proven to increase students’ comfort and willingness to treat disadvantaged populations. While many schools have such programs in place, administration should make sure these programs are positive experiences for students and patients alike. Courses (or at least lectures) that educate students about vulnerable populations should be mandatory in every dental student’s educational journey.
“Helping students to understand barriers [that Medicaid patients] face will go a long way to help them understand how to deliver education and dental care to the patients,” says Dr. Meeske. “We ask students to read thousands of pages on understanding dental diseases and dental materials but very little on social determinants of health or the science of poverty.”
In her book “Teeth,” Mary Otto writes: “The teeth are made from stern stuff. They can withstand floods, fires, even centuries in the grave. But the teeth are no match for the slow-motion catastrophe that is a life of poverty: its burdens, distractions, diseases, privations, low expectations, transience, the addictive antidotes that offer temporary relief at usurious rates.”
Sometime during our first semester of dental school, we all signed the ADA Code of Ethics and Professionalism. In doing so, we promised to do “what is good and right.” Specifically, we promised to uphold the principles of justice (“to actively help improve access to care for all”) and beneficence (“to act for the benefit of others.”) What is providing oral health care for the neediest of our fellow earthmates if not just and beneficent?
~Wendi Clanton, Georgia ’22