David is your sister’s only child and the son of 2 physicians. You’ve been a big part of his life and consequently have developed a special relationship with him. This summer marks the conclusion of his second year at college, and he has arrived at your house to ask whether you have a few minutes to chat. He tells you he thinks his strong performance as a biochemistry major will place him among the top in his class. He has observed your zeal for orthodontics, initially when he was your patient, and later working part-time in your office after school. He confides that he has a keen interest in entering a career in the health professions but is torn between a commitment to dentistry or to medicine. He is familiar with the pros and cons of both professions because of his parents’ and your own examples. You have been totally fulfilled in both dentistry and orthodontics, yet you realize that the health professions have changed significantly during your lifetime. He seeks your opinion regarding dentistry as a career “if you had the chance to do it again.”
Your response is tempered by dentistry’s current approach to the distribution of care delivery. Nine new dental schools have opened since 2008 with the intention to address insufficient dental manpower in regions of need. Yet utilization of dental services by American adults has decreased significantly in the last decade, in part because of patients’ financial concerns. The number of dentists who accept Medicaid and other forms of federal reimbursement is limited. And the concurrent bloom of several new orthodontic programs, as well as general dentists’ expanding involvement in orthodontics, suggests that strong competition for patients will be a future trend. Will more graduates address the maldistribution issue?
A survey of dentists graduating between 2005 and 2014 showed that they tend to establish their practices in urban and suburban sites rather than in underserved areas, including inner cities and rural locations. Furthermore, dentists graduating from private dental schools are less likely to practice in underserved areas than are those who graduate from public institutions. This may reflect the disparity in the educational costs faced by public vs private school graduates.
The choice of a practice location in the orthodontic specialty is similar. Orthodontists tend to locate in thriving urban and suburban areas rather than in underserved regions or areas of low-income populations. This observation is not a surprise given the availability of referral sources and the location of patients who can afford orthodontic care.
The ethical principle that reflects the fair allocation of valuable resources in a society is justice. Dental services are one such resource. Justice comprises related but separate concepts, including treating people fairly, giving them what they deserve, and providing that to which they are entitled. At first glance, these seem to be indistinct, but they are not. Providing an equal chance might be accomplished by flipping a coin. Giving people in a society what they deserve includes granting them equal opportunity for care. Providing that to which people are entitled might mean offering care to those who need it most.
The increase in the number of dental schools, and consequently dental and specialty graduates, does not adequately address the distribution of dental care. Alternative strategies are needed. With the astronomic student loans accrued by dental students and most specialty residents, some form of loan relief for those who are tempted to practice in underserved areas might be more enticing.
David is a smart guy. You should emphasize that dentistry is a great profession. But if David wants to be a total success in dentistry, his practice locale may need to be distant from yours.