The Itinerant Practice in Dentistry
It’s not what you say, it’s what they hear Frank Luntz, PhD
The purpose of this chapter is to introduce and discuss the ethics associated with itinerancy in dentistry. Members of the profession questioned on this topic would most likely focus on a specialist performing care in a generalist office. While this method of care is not uncommon, another model of care delivery seems to have an increasing incidence. This involves a practitioner who performs dental services, and for whatever reason, elects to work for remuneration without a motivation to achieve ownership in a practice.
Principles of Ethics and Code of Professional Conduct
As dentistry moved up the evolutionary trail from a trade to a profession, emphasis on higher education, state licensure, defined standards of care, and ethics were promoted by both the public and members of the profession. In effect, the public expected a “professional” to have the patient’s best interest considered while peer associations were formed to address ethical standards of care and continuing education in the practice of dentistry. To be a member of a professional association (e.g., American Dental Association), one is required to acknowledge and abide by that associations Principles of Ethics and Code of Professional Conduct. A failure to do so may result in minor to serious punishment by the association (e.g., letter of counsel or expulsion from membership). When an association issues a serious punishment to a member, they are required to send the information to the National Practitioner Databank, which may impact state licensure, purchase of liability insurance, or membership in other peer associations.
Note: The practice of dentistry in each State is governed by a Dental Practice Act Statute which is regulated by an agency of the state (e.g., state board of dental examiners), which enhances the statute by codifying rules and regulations. This is the legal aspect for the practice of dentistry in a state. The ethical standards of practice are developed by the dental profession itself and are administered by the association in which a dentist is a member. Therefore, all violations of a dental practice act and associated rules and regulations of a state are not only illegal, but are unethical acts as well, but the reverse is not true in that not all unethical acts are illegal.
Definition and History of Itinerant Healthcare
The term itself refers to one who travels from place to place to perform his or her work. In the earliest healthcare, the provider would travel from location to location because of a deficiency of providers in underserved areas. As provider volume and competition increased, fewer generalists found the need to travel and thus settled in one community. As medical specialization increased, some (e.g., surgeons) would travel to perform surgery and then leave follow-up care to the general practitioner in the area. This trend caused the American College of Surgeons to address the itinerant practice of surgery in 1974, with revisions in 1997. Arguments to benefit patient care promoted the premise that the most qualified and best trained practitioner in a specialty area should not delegate certain care to a lesser trained practitioner. This core principle of ethics survives today.
Note: While there are associations under the umbrella of dentistry that have addressed the “itinerant practice” of its members, The Principles of Ethics and Code of Professional Conduct of the American Dental Association does not specifically address the term.
Itinerant Practice for the Dental Specialist
The proven treatment delivery model for specialty care in dentistry today remains the same as it has been for decades. Upon completion of residency training, graduates commonly enter an existing practice as associates, with the future plan of a buy-in or buy-out or they open their own office in a chosen community. Historically, as relationships were developed with referral practitioners, patients were sent to the specialist’s office for care. On occasion the specialist may travel to an underserved area, but the majority of his productive time was spent in his/her own facility. Advantages to both the practitioner and patient would be: 1) an office specifically designed and utilized daily to meet practice requirements 2) availability of special equipment 3) a staff with very specific training in the limited procedures of the practice and 4) post treatment care rendered by the specialist. Patient disadvantages may include travel to an unfamiliar office location that may be farther from their home.