Considering a surgical operation? You might want to check who’s going to deliver the anesthetic—and assess your own comfort level with that person if he or she is not a physician. If a new Health Care Financing Administration ruling is allowed to stand, a long-standing policy requiring physicians to supervise nurse anesthetists will be history. Physicians aren’t pleased.

Commenting on the new ruling, the president of the American Medical Association remarked that the action "ignores the substantial differences in training between physicians and nurse anesthetists." To emphasize his point, he contrasts the physician’s minimum of seven years of training, including hands-on hospital residence experience, with the lack of even bachelor’s-degree education for one-third of the nurse anesthetists.

Physician anesthesiologists have been even more vocal, commenting that "the underlying motivation for the rule was political, totally ignoring safety and science." The anesthesiologists plan to take their fight to the states where state medical practice acts still can impose legal constraints against the unsupervised practices of nurse anesthetists.

The movement toward unsupervised practice is hardly confined to nurse anesthetists or nurse practitioners. In Illinois, pharmacists want to "initiate, monitor and modify prescribed drugs." Physicians say "no" to these pharmacists, who want to practice medicine by having "patients" come in and describe their symptoms, followed by the pharmacist prescribing a drug or changing a dosage. Illinois also has added physician assistants to the list; they’re seeking legislation to conduct and sign off on school physical examinations.

The growing issue of nonphysician clinicians’ becoming independent practitioners is particularly disturbing to me. For years, I have advocated that, at least in the first stages of a perceived work-force shortage, additional allied dental personnel, not dentists, should be trained to help address inequities in work-force numbers and distribution. Unfortunately, there is a potential danger in pursuing this course of action.

History demonstrates that having obtained the expanded clinical training, one or more members of the newly trained group will argue that they can provide the same service as the original provider to more people and at lower cost. Vocal and well-organized, they often have been able to convince lawmaking bodies to change state practice acts in their favor.

Take denturists, for example. Because of their small number, their clinical activities rarely attract nationwide attention. In fact, a recent ADA survey indicated that the dental profession is "not at all concerned" about these independent practitioners. Perhaps it should be.

Ask the Montana State Board of Dentistry, which recently advised several denturists not to use the acronym D.D.M. or the title Doctorate of Medical Denturity. Close to dentistry’s D.M.D., isn’t it? Undaunted, Montana denturists sought a ruling that would allow them to evaluate temporomandibular joint disorders. Again, the board of dental examiners ruled that denturists cannot diagnose or treat these disorders. Similarly, the board of education responded negatively to a denturist request to be the accrediting agent for denturism education programs.

These issues aside, my personal concern rests in the potential fragmentation of care, especially in the detection of oral lesions by unsupervised denturists. Maine recognizes the issue and requires that a dentist examine the patient within 30 days before a denturist can begin fabricating the patient’s denture.

In Oregon, the denturist must obtain an oral health certificate from a dentist or physician before initiating treatment, but that requirement can be waived if the denturist has had additional training in oral pathology. That exemption troubles me. What level of training for these unsupervised denturists will bring them to the competence level of a dentist?

I have the same issue with the unsupervised practice of dental hygiene. New Mexico, one of the six states that allow the hygienist either limited or total unsupervised practice, provides that "qualified hygienists may own and manage a hygiene practice and may advise a patient of suspected pathology and periodontal status, though they may not diagnose dental disease."

What differentiates advising a patient of suspected pathology from actually making a diagnosis? Ultimately, the issue is this: do unsupervised hygienists have the same level of training in oral medicine and oral pathology as dentists? If not, then it’s the patient who suffers.

Contrary to statements often made by hygienists seeking unsupervised practices, dental hygiene students or graduates do not receive the same level of basic science and clinical training as dental students. While technical proficiency in certain procedures can be achieved equally by dentists and allied dental personnel, diagnosis, treatment planning and outcome evaluation cannot.

Then there is the issue of continuity of care—dentistry’s one big claim of supremacy over medicine. Because we are a profession dominated by general practitioners, the bulk of care provided to any one patient is delivered by one professional. Start taking off a little chunk here and another piece there and it doesn’t take too long until no one is in charge of the patient’s health needs—and again, the patient suffers.

If branching off from the parent and creating independent domains is inherent in systems that allow delegation of duties to lesser-trained people, how can the dental profession minimize the number of expanded-duty allied dental personnel who seek unsupervised practice?

Foremost, dental practitioners need to provide a stimulating work environment, with sufficient reward systems to acknowledge the performance excellence of dental team members. Continuing education opportunities supported by the dental office should be built on the concept of upward mobility. The ideal endpoint of professional advancement should be admission to dental school with advanced standing. Becoming a dentist, not an independent nondentist clinician, should be the desired outcome.

Professional efforts need to focus on legislative actions that ensure that expanded duties for allied dental personnel do not infringe on the dentist’s unique abilities to diagnose conditions and plan treatment. While this has been the prevailing philosophy of the dental profession, continued oversight is needed to guard against capricious political actions that would lead to lower standards of care.

If the dental work force is to be augmented mainly with expanded-duty allied dental personnel, implementation of these two suggestions should alleviate many of the previously noted problems. Regardless of any successful programmatic outcomes, professional vigilance must never be relaxed. Intrusions by lesser-trained people into the dentist/patient relationship should not be tolerated.