raskin px didnt know aaa 2013 11 26

Raskin – “Patients Don’t Know” – AAA 2013 DRAFT 11.26 – Please don’t cite without permission p. 1

“The patients didn’t know who was supposed to be doing what”: Expertise, subjectivities and the mid-level dental provider Sarah Raskin, MPH, ABD, University of Arizona American Anthropology Association Annual Meeting Panel: “When the Doctor Is Not In” November 22, 2013

Introduction

A few months ago while perusing DrBicuspid.com, one of my favorite sources for dental industry

news, I came across a commentary by David Nash, an endowed professor of community dentistry and a

frequent contributor to debates over access to dental care. Nash had co-authored one of two recent

reviews of the evidence on dental therapists, mid-level dental providers licensed to work in 54 countries

and proposed to be added to the U.S. dental workforce (See Nash, Friedman, Mathu-Muju, et al. 2012;

Wright, Graham, Hayes, et al. 2013). Both reviews were favorable toward dental therapists in terms of

economics, increasing access to care, and safety and quality. In fact, it was the evidence that dental

therapists performed not only as well as dentists in general, but better than dentists on select

outcomes, that prompted Nash’s snarkiest observation. The American Dental Association – which

commissioned one of the reviews – he said, must surely be disappointed.

I have followed the debate over dental therapists as part of my research on oral health and

dental care in a large, rural Dental Health Professional Shortage Area, and Nash’s editorial caught my

eye because it layed bare one of the hidden stakes of the debate over dental pluralization: status. While

the nuances of the debate over the expansion of dental mid-levels roles are specific to the histories of

the dental professions, state practice law, and other factors, the debate itself is entirely predictable.

Pluralization and expansion are a canonical feature of governance in late modernity and of medical care

within a neoliberal milieu (Dean 2010 following Foucault 1991). Scholars have argued that expertise and

all it confers is a fundamentally unstable but deeply endowed construct through which professions


engage in “micro-political struggles” (Salhani and Coulter 2009:1221) that construct social order more

broadly (Carr 2010; Hogle 2002; Johnson 1995; Martin 2009).

In this paper, I explore the micro-political struggles of dental expertise as they play out in one

site that has become synonymous in the popular imaginary with poor oral health and inadequate access

to care: central Appalachia. Drawing on fifteen months of ethnographic research in far southwest

Virginia, I show how paradoxes in the distribution of dental tasks, are, rather than diversions from the

organization of dental care under a “team” model, constitutive of them, especially in a site of medical

or, in this case, dental abandonment. I counterpose providers’ perspectives on the expansion of mid-

level care with descriptions of everyday practice to show how the terms of dental team work are already

being renegotiated within a local “moral assemblage”(Zigon 2011), with little regard for national

debates. I argue that these paradoxes reshape professional subjectivities in some important ways, while

re-entrenching existing norms in others.

Expanding Access to Care: The Stakes of the Debate

Dental care in the US has been described as a crisis (Sanders 2012). Over a third of adults lack

dental insurance, and delay or refusal of treatment is typical among many who are insured, for lack of

adequate coverage or resources to cover expensive co-payments (National Association of Dental Plans

2012). Over 2 million people seek treatment for dental pain and infection at hospital emergency rooms

annually, while thousands more attend charity clinics where they wait – outdoors, overnight, as in my

field site — to get multiple teeth extracted each year until they are completely toothless, then return

the next year in hopes of winning the “denture lottery” (Igo 2013; Mahaskey 2013; Wall and Nasseh

2013). Poor oral health has profound medical and social sequelae, and is implicated in other illnesses,

from its worsening effects on diabetes, pregnancy, and addiction, to its primacy in death from systemic

infection (Boggess and Edelstein 2006; Demmer, Jacobs and Desvarieux 2008; Mateos-Moreno, del-Río-

Highsmith, Riobóo-García, et al. 2013; Nalliah, Allareddy, Elangovan, et al. 2011).


Only in the last decade have attempts been made, mostly in response to new recognition of the

role of oral health in overall health, to shift the model of dental care from one of entrepreneurship to

one of service. Key to many proposals to improve the prevention and treatment of oral disease is

workforce expansion, especially critical as dental school graduation rates do not match dentistry’s

retirement rate, and, as in medicine, more and more graduates enter specialties over general practice

(Henderson 2004; Okwuje, Anderson and Valachovic 2010; Solomon 2009). Many workforce proposals

include the expansion of existing “auxiliary” roles as they were previously called by dentists, such as

advanced dental hygiene practitioners or the development of new “mid-level” professionals such as

dental therapists, technically-oriented workers tasked with the duties of prevention and basic care. They

are specifically envisioned to reach out to marginalized populations such as racial and ethnic minorities,

rural residents, and impoverished people, especially impoverished children. Many of the tasks

envisioned to be the responsibilities of semi-autonomous mid-level dental providers are already

performed by dental hygienists and assistants, for example patient education, topical treatments, a few

basic procedures, and some simple restorations,. Yet, the greatest opposition to mid-level initiatives

comes not from existing hygienists or assistants, who one would expect to feel threatened by the

emergence of a competitor, but from dentists, ostensibly their employers and supervisors and, one

could argue, beneficiaries.

How Do Dental Teams Work, Officially?

To better understand how new mid-level dental providers would enter into models of dental

care, we can look at how dental teams work now. Dental hygienists and assistants perform an array of

duties under a variety of supervision structures that vary by state, for example general supervision, in

which they perform procedures approved by a dentist who has examined the patient, but who does not

have to be present in the room to supervise clinical work, directly. Charles, a general dentist in my

fieldsite, offered an example:


My brand new hygienist…is licensed to give anesthesia. Local. That’s a big help to me to get more care delivered. She can get somebody numb while I’m doing something else. You know, I walk in, all of a sudden I’m ready to do the filling or whatever…If you could get where my expanded function assistants could actually place the restorations and make temporaries and do a lot of the hands-on care, I think that would be a huge step toward being able to deliver more quality care because these girls, and I say girls because most of them are girls, are very meticulous and they are able to do things that I think dentists over time tend to see as sort of somewhat menial tasks.

This discussion led me to ask Charles his perspective on proposals to develop the dental therapy

profession. He said he opposed them. One of my first dentist participants, I was surprised. He had spent

much of our conversation venerating his employees’ skills and judgment, and I had expected that stance

to extend to other dental team members. But Charles said no. The dental therapist profession was being

established from outside of dentistry, as opposed to hygienists and assistants, which were developed

from within it, and that fact made him suspicious that dental therapists would eventually work to “hang

a shingle.” He didn’t agree with that. He thought that all dental teams members should still “answer to

an overseer, a dentist.”

Charles’ perspective on dental teamwork was common among dentists I interviewed, and it tells

us a lot about how dental professional subjectivities are re-asserted paradoxically through dental

teamwork. For example, dentists see themselves as business savvy in hiring highly skilled workers in

order to offer more patient care, increase the practice’s profitability (“productivity” in dental practice

lingo), and free themselves up to do the more exciting work of dental practice. While most dentists are

open to innovation, such as their “girls” doing “most of the hands on work,” almost everyone I

interviewed is still committed to maintaining the dental hierarchy, a hierarchy that is, clearly, gendered.

Interviews with dentists revealed an additional, highly ironic, trait of dental task assignment. As Vince, a

second generation dentist in the region, told me, “root canals, fillings, crowns -- What we do here is not

rocket science. Anybody can do it.” So I asked him who “anybody” was, and if “anybody” might be a

mid-level dental provider. “Absolutely not,” he said. “You’re throwing too much responsibility on people

when they start taking out teeth or filling teeth.” As I learned, the paradoxes that characterize such


discourse are also enacted as inconsistencies in practice. Dental hygienists and assistants, cast

simultaneously as “meticulous” and inadequately “responsible” to perform some of the work of basic

dental care, are already, as it turns out, doing it.

How Else do Dental Teams Work?

I met Michelle through a key informant. A dental hygienist who preferred clinical tasks to the

educational ones that characterized most of her current work in a school outreach program, she once

told me about her best job ever, working for a periodontist:

Sometimes he would let me scale and plane the subgingiva (that is, use an instrument to remove build-up below the gumline). He (saw) what a good job I did removing the calculus up above it. Man, I’m so OCD, I just LOVE to flick it off. He knew I was meticulous and could handle the equipment better than most dentists. So he would point to the hand scaler and say ‘you know what to do.’

“Michelle!” shrieked her friend and colleague Jennifer, “Weren’t you worried about getting caught? You

could have your license revoked for that!” Michelle shrugged off Jennifer’s concern. “I didn’t worry too

bad,” she said, “The patients didn’t know who was supposed to be doing what and the dental board

wasn’t gonna come all the way down here to investigate something little like that. Besides, dental

hygienists in other states get to do it all the time!”

Whereas dental hygienists in several states are allowed to treat the area below the gumline, in

no state is an unlicensed dental assistant allowed to clean teeth, a practice common among older

dentists in my fieldsite who employ their wives as assistants. Similarly, in very few states are dental

hygienists or assistants licensed to do extractions, a procedure that, when simple – meaning, without

need for surgical anesthesia – some proposed dental mid-levels would be able to do. But for Sarah, a

dental assistant whose employer, in her words, “really” needs to retire, her lack of authorization to

extract posed a moral quandary: Her boss was losing the physical strength to extract teeth well, and he

had already lost the eyesight and level of concentration to reliably numb — and extract — the correct

one. On a number of occasions, she guided his needle to inject anesthesia, his instruments to cut into


the right area, and, on one occasion, his hands to help him pull the tooth out. Conscientious and mild-

mannered, Sarah felt morally wrought: She didn’t want to practice outside of her legal scope. But she

didn’t want her boss to practice what participants in my research called “poor dentistry” either.

Michelle and Sarah’s narratives show how new professional subjectivities emerge through both

explicit and tacit redistributions of clinical tasks. Sarah reluctantly worked outside of her scope of

practice, based on her feelings of commitment to her patients and, perhaps, to her employer. Michelle

was empowered by her employer to do work to which he felt she was well-matched and sufficiently

skilled – more skilled than some dentists. These reconfigurations of subjectivity occur outside of official

discourses, for example, the national dental therapist debate. They also occur outside of legal statute.

As Jennifer pointed out to Michelle, embodying these hybrid, illicit subjectivities – more than dental

hygienist or assistant, less than dentist – bears considerable legal and ethical risk, perhaps more risk

than even those dentists who practice “poor dentistry” for, questions of quality aside, those dentists are

still working within their legal scope of duty

Do Existing Midlevels Want to Formalize New Dental Subjectivities?

In my reading on proposed mid-level dental providers, one of the most striking is the lack of

attention to the perspectives of people who might inhabit these new roles – for example dental

assistant who might want to become dental therapist, or potential new professionals who would train to

enter the profession. So I asked research participants under what circumstances, if any, would they

consider becoming an official mid-level provider?

Johnna, a dental hygienist and aspiring dentist said she would “love” to become mid-level

provider. “That would solve my problem,” she said,

Because going back to school for only three or four years would be a lot better than going back for six or seven (for dentistry)… even if it was just doing extractions and fillings…I would do that in a heartbeat and I think it’s needed in this area because…it’s hard getting any (dentists) to come here…You hear people talk, they think Lee County is a cesspool, but I like it here.


A first generation college graduate with straight A’s who wants to provide her home community the

services deemed boring and rote by dentists, services they sometimes allow their “auxiliaries” to

perform illicitly, Johnna is precisely the “type” of person envisioned by proponents of dental mid-levels

to enact its emergent subjectivity. But she is rare among dental hygienists and assistants I know.

Sarah said, unequivocally, no. With twenty-five years’ experience working as a dental assistant,

she felt closer to retirement than returning to school just to formalize things she was already doing.

Michelle, also, said no. Like Charles, she believed that new mid-level dental professional models would

quickly move toward independent practice, like nurse-practitioners, and she just didn’t want to take on

the risks and burdens of entrepreneurship. Sarah and Michelle were in the majority among dental

hygienists and assistants I interviewed. Working mothers, many of them single or the primary earners in

the family, they juggled the obligations of family and home with those of offices whose schedule

flexibility they appreciated.

Conclusion

Epstein observes that the medical professions are a special case of expertise, in which it is “not

just social authority (that is) rooted in the division of labor…but also cultural authority” (Epstein

2009:411; see also Picard 2009; Starr 1982). His observation resonates with the current debate over

dental mid-level initiatives, in which dentists attempt to dictate the terms of even those tasks that, in

dentists tell me they “aren’t trained to do,” such as health education or prophylactic cleanings, or, find

“rote” or “boring,” such as basic restorations. Epstein’s perspective also resonates with shifting practices

in my fieldsite, in which dental tasks are renegotiated in ways that are, alternately, creative, threatening,

illegal, empowering, and, most of all, opening of attempts to salvage and expand what few dental care

opportunities exist for poor rural patients.

While these changes foster the emergence of some new professional subjectivities while re-

entrenching others, they also implicate patient subjectivities in affirming the cultural authority of


providers, as identified by Epstein. Many patients, as Melissa said, “don’t know who is supposed to be

doing” which task. A few others, however, were very clear about the ways in which their dental care was

shaped by dental team composition and relations so, by extension, dental provider subjectivities and the

traits of cultural authority, such as setting the tone in the clinical encounter. For example as Flora, a

long-term patient of Sarah’s dentist told me, “Sarah’s what’s running that dental clinic right now…Last

time, the dentist tried to pull the wrong tooth! He was getting ready to numb the wrong one until Sarah

shown him. She tried to talk quiet so I wouldn’t hear. Bless her heart, she didn’t want to hurt his

feelings.” Dentists may be able to limit the tasks authorized to new dental team roles, and may be able

to maintain dental hierarchies officially, but in moments such as these, in which underserved patients

value trust and compassion as highly as clinical skill, the dental subjectivities of mid-levels are re-

enacted in fascinating, powerful, and affirming, new ways.

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