mike3kgt

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Saw this on msnbc.com today:

For us fellow dentists... just replace "doc" or "physician" or "doctor" with "dentist" and also replace "nurse" or "nurse practitioner" with "dental health aide therapist" or "advanced dental hygiene practitioner"... Congrats, you are now in the year 2020/2030.

And the ADA thinks more medicaid funding for dentists is more important than expansion of mid-level providers. HAH.

----------------------------

Doc deficit? Nurses' role may grow in 28 states
Nurse practitioners want right to prescribe narcotics, AMA fights proposal

By CARLA K. JOHNSON
AP Medical Writer
The Associated Press
updated 4:53 p.m. ET, Tues., April 13, 2010

CHICAGO - A nurse may soon be your doctor.

With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called "Doctor."

For years, nurse practitioners have been playing a bigger role in the nation's health care, especially in regions with few doctors. With 32 million more Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.

Those newly insured patients will be looking for doctors and may find nurses instead.

The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association, which supported the national health care overhaul, says a doctor shortage is no reason to put nurses in charge and endanger patients.

Nurse practitioners argue there's no danger. They say they're highly trained and as skilled as doctors at diagnosing illness during office visits. They know when to refer the sickest patients to doctor specialists. Plus, they spend more time with patients and charge less.

"We're constantly having to prove ourselves," said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she's just like a doctor "except for the pay."

On top of four years in nursing school, Cockrell spent another three years in a nurse practitioner program, much of it working with patients. Doctors generally spend four years in undergraduate school, four years in medical school and an additional three in primary care residency training.

Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85 percent of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.

The health care overhaul law gave nurse midwives, a type of advanced practice nurse, a Medicare raise to 100 percent of what obstetrician-gynecologists make — and that may be just the beginning.

States regulate nurse practitioners and laws vary on what they are permitted to do:
# In Florida and Alabama, for instance, nurse practitioners are barred from prescribing controlled substances.
# In Washington, nurse practitioners can recommend medical marijuana to their patients when a new law takes effect in June.
# In Montana, nurse practitioners don't need a doctor involved with their practice in any way.
# Many other states put doctors in charge of nurse practitioners or require collaborative agreements signed by a doctor.
# In some states, nurse practitioners with a doctorate in nursing practice can't use the title "Dr." Most states allow it.

The AMA argues the title "Dr." creates confusion. Nurse practitioners say patients aren't confused by veterinarians calling themselves "Dr." Or chiropractors. Or dentists. So why, they ask, would patients be confused by a nurse using the title?

By 2015, most new nurse practitioners will hold doctorates, or a DNP, in nursing practice, according to a goal set by nursing educators. By then, the doctorate will be the standard for all graduating nurse practitioners, said Polly Bednash, executive director of the American Association of Colleges of Nursing.

Many with the title use it with pride.

"I don't think patients are ever confused. People are not stupid," said Linda Roemer, a nurse practitioner in Sedona, Ariz., who uses "Dr. Roemer" as part of her e-mail address.

Quality of care same as docs, study finds
What's the evidence on the quality of care given by nurse practitioners?

The best U.S. study comparing nurse practitioners and doctors randomly assigned more than 1,300 patients to either a nurse practitioner or a doctor. After six months, overall health, diabetes tests, asthma tests and use of medical services like specialists were essentially the same in the two groups.

"The argument that patients' health is put in jeopardy by nurse practitioners? There's no evidence to support that," said Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health.

Other studies have shown that nurse practitioners are better at listening to patients, Needleman said. And they make good decisions about when to refer patients to doctors for more specialized care.

The nonpartisan Macy Foundation, a New York-based charity that focuses on the education of health professionals, recently called for nurse practitioners to be among the leaders of primary care teams. The foundation also urged the removal of state and federal barriers preventing nurse practitioners from providing primary care.

AMA fighting proposals to expand care
The American Medical Association is fighting proposals in about 28 states that are considering steps to expand what nurse practitioners can do.

"A shortage of one type of professional is not a reason to change the standards of medical care," said AMA president-elect Dr. Cecil Wilson. "We need to train more physicians."

In Florida, a bill to allow nurse practitioners to prescribe controlled substances is stalled in committee.

One patient, Karen Reid of Balrico, Fla., said she was left in pain over a holiday weekend because her nurse practitioner couldn't prescribe a powerful enough medication and the doctor couldn't be found. Dying hospice patients have been denied morphine in their final hours because a doctor couldn't be reached in the middle of the night, nurses told The Associated Press.

Massachusetts, the model for the federal health care overhaul, passed its law in 2006 expanding health insurance to nearly all residents and creating long waits for primary care. In 2008, the state passed a law requiring health plans to recognize and reimburse nurse practitioners as primary care providers.

That means insurers now list nurse practitioners along with doctors as primary care choices, said Mary Ann Hart, a nurse and public policy expert at Regis College in Weston, Mass. "That greatly opens up the supply of primary care providers," Hart said.

But it hasn't helped much so far. A study last year by the Massachusetts Medical Society found the percentage of primary care practices closed to new patients was higher than ever. And despite the swelling demand, the medical society still believes nurse practitioners should be under doctor supervision.

The group supports more training and incentives for primary care doctors and a team approach to medicine that includes nurse practitioners and physician assistants, whose training is comparable.

"We do not believe, however, that nurse practitioners have the qualifications to be independent primary care practitioners," said Dr. Mario Motta, president of the state medical society.

The new U.S. health care law expands the role of nurses with:
# $50 million to nurse-managed health clinics that offer primary care to low-income patients.
# $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.
# 10 percent bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners, who work in areas where doctors are scarce.
# A boost in the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor's.

The American Nurses Association hopes the 100 percent Medicare parity for nurse midwives will be extended to other nurses with advanced degrees.

"We know we need to get to 100 percent for everybody. This is a crack in the door," said Michelle Artz of ANA. "We're hopeful this sets the tone."

In Chicago, only a few patients balk at seeing a nurse practitioner instead of a doctor, Cockrell said. She gladly sends those patients to her doctor partners.

She believes patients get real advantages by letting her manage their care. Nurse practitioners' uphill battle for respect makes them precise, accurate and careful, she said. She schedules 40 minutes for a physical exam; the doctors in her office book 30 minutes for same appointment.

Joseline Nunez, 26, is a patient of Cockrell's and happy with her care.

"I feel that we get more time with the nurse practitioner," Nunez said. "The doctor always seems to be rushing off somewhere."
Copyright 2010 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

URL: http://www.msnbc.msn.com/id/36472308/ns/health-health_care/

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© 2010 MSNBC.com
 

gryffindor

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The overhead for the fields where these nurse practitioners are trying to play doctor is a prescription pad and a couple of tongue depressors. I saw an MD derm recently and then saw his nurse practitioner at the followup and both times they spent $0 on supplies to examine me. No gloves, no gauze, nothing. Seeing a dental patient requires a pair of gloves and at least a mirror regardless of whether you are a DHAT or DDS. Therefore, I still can't figure out how a DHAT is going to do an amalgam cheaper than me. So if an average DDS practice has an overhead of 60%, then are these DHATs are going to run practices with overheads of 90% because the only place I can see that they can cut cost in dentistry is the profit margin on the labor.
 
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The overhead for the fields where these nurse practitioners are trying to play doctor is a prescription pad and a couple of tongue depressors. I saw an MD derm recently and then saw his nurse practitioner at the followup and both times they spent $0 on supplies to examine me. No gloves, no gauze, nothing. Seeing a dental patient requires a pair of gloves and at least a mirror regardless of whether you are a DHAT or MD. Therefore, I still can't figure out how a DHAT is going to do an amalgam cheaper than me. So if an average DDS practice has an overhead of 60%, then are these DHATs are going to run practices with overheads of 90% because the only place I can see that they can cut cost in dentistry is the profit margin on the labor.
:thumbup:
The only way I could see how DHAT's could fit was if they worked as an employee of a dentist, and made a % of the profit margin from each procedure. This could allow the dentist handle a larger load without having to hire a more expensive associate. If this is what happens, dental students coming out of school could find jobs as associates harder to find. (take my opinion with a grain of salt, I just starting D-school this fall)
 

dl9006

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States regulate nurse practitioners and laws vary on what they are permitted to do:
# In Florida and Alabama, for instance, nurse practitioners are barred from prescribing controlled substances.
# In Washington, nurse practitioners can recommend medical marijuana to their patients when a new law takes effect in June.
# In Montana, nurse practitioners don't need a doctor involved with their practice in any way.
# Many other states put doctors in charge of nurse practitioners or require collaborative agreements signed by a doctor.
# In some states, nurse practitioners with a doctorate in nursing practice can't use the title "Dr." Most states allow it.

The AMA argues the title "Dr." creates confusion. Nurse practitioners say patients aren't confused by veterinarians calling themselves "Dr." Or chiropractors. Or dentists. So why, they ask, would patients be confused by a nurse using the title?
this is stupid..
then how would you differentiate a MD who spent almost a decade in school vs a nurse doctor who spent 4 years in nursing school?

everyone in the hospital would be called Dr. :laugh:

at least chiropractors and dentists(most of the time) do not work in the same workplace as MDs thus saving any confusion.
why fool the patient?

this is just an attempt to boost their egos.
if you love your job then title shouldn't be an issue


By 2015, most new nurse practitioners will hold doctorates, or a DNP, in nursing practice, according to a goal set by nursing educators. By then, the doctorate will be the standard for all graduating nurse practitioners, said Polly Bednash, executive director of the American Association of Colleges of Nursing.

Many with the title use it with pride.

"I don't think patients are ever confused. People are not stupid," said Linda Roemer, a nurse practitioner in Sedona, Ariz., who uses "Dr. Roemer" as part of her e-mail address.
I like how she desperately wants to play doctor. lol if i ever get sick, please give me a real doctor so that i don't have some under-trained nurse with an inflated sense of self injecting me
......
 
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mike3kgt

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Your statement is absolutely correct. What I love is the pre-med freaks who are obsessed with the title "Doctor" and what new reality the future of healthcare offers them in terms of "prestige." What a joke.

I don't mind, hell, I encourage it, when patient's call me Dr. Mike or just plain Mike because I know that I offer them a service that few other dentists can offer and, frankly, no hygienist or 2-year M.S. or high school graduate calling themselves a "therapist" could EVER offer a patient. The doctor thing is overrated, and the white coat thing is stupid. Get over it... doctor is a teacher and frankly any dentist can out-educate and out-reason why certain things happen with patients far and above any mid-level provider.
 

dentalWorks

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Can someone please explain to me this whole deal with "mid-leve" providers? What exactly is this?

Are we talking about a specialist that is in between a hygienist and a dentist? Basically they do the simple stuff dentists do, but cheaper?

I am not trying to start an argument, I just wanna learn more about this... as this seems to be the future of all of healthcare
 

DrJeff

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Can someone please explain to me this whole deal with "mid-leve" providers? What exactly is this?

Are we talking about a specialist that is in between a hygienist and a dentist? Basically they do the simple stuff dentists do, but cheaper?

I am not trying to start an argument, I just wanna learn more about this... as this seems to be the future of all of healthcare
That's basically what is being propsed.

It seems that the two main models being looked at are the Dental Health Aide Therapist (DHAT) - basically has the ability to practice under the direct supervision of a dentist(dentist in the building and checking the diagnosis and treatment done and the Advanced Dental Hygiene Practitioner (ADHP) who could practice under indirect supervision of a dentist (dentist not in the same building but available via some form of communication.

The biggest thing in both situations is going to be develo[ing a standardized curriculum and testing/certification processes. Oh yah, and that little thing about how to deal with the overhead of a dental office(read as how much gov't subsidy will be needed to support most mid-level situations)
 

SeattleRDH

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There is a BIG difference between the DHAT and the ADHP. DHAT's go through a two year training program. The only prerequisite is a highschool education. ADHP's already went to two years of hygiene school, completed a bachelor's degree, and went on to get a master's. 2 yrs education vs. 6 yrs education....

Those of us working in hygiene know that there is NO WAY we could cover the overhead of a dental office on cleanings and simple fillings alone. Most of these providers would be working in gov't health clinics. Maybe more dentists should get out of private practice and into public health... HA! I'll believe it when I see it.
 

dentalWorks

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That's basically what is being propsed.

It seems that the two main models being looked at are the Dental Health Aide Therapist (DHAT) - basically has the ability to practice under the direct supervision of a dentist(dentist in the building and checking the diagnosis and treatment done and the Advanced Dental Hygiene Practitioner (ADHP) who could practice under indirect supervision of a dentist (dentist not in the same building but available via some form of communication.

The biggest thing in both situations is going to be develo[ing a standardized curriculum and testing/certification processes. Oh yah, and that little thing about how to deal with the overhead of a dental office(read as how much gov't subsidy will be needed to support most mid-level situations)
But these DHAT/ADHP aren't going to be shoved down our throats... right? I mean if you own your own practice, theyr not going to make you hire a DHAT or ADHP... are they?
 

aphistis

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There is a BIG difference between the DHAT and the ADHP. DHAT's go through a two year training program. The only prerequisite is a highschool education. ADHP's already went to two years of hygiene school, completed a bachelor's degree, and went on to get a master's. 2 yrs education vs. 6 yrs education....

Those of us working in hygiene know that there is NO WAY we could cover the overhead of a dental office on cleanings and simple fillings alone. Most of these providers would be working in gov't health clinics. Maybe more dentists should get out of private practice and into public health... HA! I'll believe it when I see it.
Maybe more hygienists should stick to doing hygiene... HA! I'll believe it when I see it.
 
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mike3kgt

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Are we talking about a specialist that is in between a hygienist and a dentist? Basically they do the simple stuff dentists do, but cheaper?
Supposedly, cheaper, and intially, maybe...

A major purpose of posting the article I read is that I got so incredibly angry when I saw the information regarding reimbursement rates for NPs vs. MDs. The nursing association feels they should be reimbursed equivalent to that of the fee schedule of their physician friends.

------

--This is how it starts out in dentistry. We purport the *NEED* for midlevel providers to serve the access to care gap by filling in between care and indigent care. Mandates to work in rural or poor communities at first.

--Then comes the desire to allow the group to have their own medicaid/medicare/NPI number so they can independently receive reimbursement from dentists.

--Then comes the desire to be independent of dentists to "better access"

--Then comes the argument "why are we forced to work against our will in these communities when we have been proven to work well with the public and don't lead to harm upon them?" So they want to live the American dream right? Human nature, they want to set up hygiene mills/extraction mills in shopping malls etc to maximize production.

--Then, as this article states, they want to seek equal reimbursement with dentists because they still feel dejected because they do the "same work for less pay".

-----

It's called a slippery slope, it's a clear as day unless you have your head in the sand.

Why not go against them before they have their own organization of crazy liberal women (ADHA) like dentistry has been for the past 80+ years?
 

SeattleRDH

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Supposedly, cheaper, and intially, maybe...

A major purpose of posting the article I read is that I got so incredibly angry when I saw the information regarding reimbursement rates for NPs vs. MDs. The nursing association feels they should be reimbursed equivalent to that of the fee schedule of their physician friends.

------

--This is how it starts out in dentistry. We purport the *NEED* for midlevel providers to serve the access to care gap by filling in between care and indigent care. Mandates to work in rural or poor communities at first.

--Then comes the desire to allow the group to have their own medicaid/medicare/NPI number so they can independently receive reimbursement from dentists.

--Then comes the desire to be independent of dentists to "better access"

--Then comes the argument "why are we forced to work against our will in these communities when we have been proven to work well with the public and don't lead to harm upon them?" So they want to live the American dream right? Human nature, they want to set up hygiene mills/extraction mills in shopping malls etc to maximize production.

--Then, as this article states, they want to seek equal reimbursement with dentists because they still feel dejected because they do the "same work for less pay".

-----

It's called a slippery slope, it's a clear as day unless you have your head in the sand.

Why not go against them before they have their own organization of crazy liberal women (ADHA) like dentistry has been for the past 80+ years?
"crazy liberal women" is a very sexist statement. The ADHA is a professional organization. And why this assumption that mid-level providers will be all women? I hate to tell you this but there are female dentists! They must be crazier liberal women!
 
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mike3kgt

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I hate to tell you this but there are female dentists!
Haha, I thought my comment would get some excitement. My wife is a dentist so I'm a big fan of female dentists, hahaha, she thinks the ADHA is full of crazy liberals too :). I also know a few RDHs who are prominent members of the ADHA who silently keep quiet because they disagree about their organization's stance on professional advancement.
 
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The central issue is access to care.

I call on all dentist to volunteer at local community clinics to help alleviate this issue.

I realize many new grads have a ton of debt and dentistry is hard physical work esp at the community clinic setting. BUt if we don't take matters to our own hands it will be taken away from us all in the name of access to care (even though we know the reasons to push for professional advancement for the ADHA is for ego and to gain more respect).
 

SeattleRDH

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are dental mid-level providers available now? or this is something thats going to start soon?
It depends how you define mid-level provider. Every state is different. In Alaska DHATs are only out working in native health clinics. The ADHP is only in pilot programs in certain states. In Washington hygienists are licensed to do restorative. In Pennsylvannia hygienists can't even do anesthetic. It really should be standardized.

This is my opinion in a nutshell:

DHATs = bad
ADHP = ok (but no irreversible procedures)
More dentists in rural & public health = best
 
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The central issue is access to care.

I call on all dentist to volunteer at local community clinics to help alleviate this issue.

I realize many new grads have a ton of debt and dentistry is hard physical work esp at the community clinic setting. BUt if we don't take matters to our own hands it will be taken away from us all in the name of access to care (even though we know the reasons to push for professional advancement for the ADHA is for ego and to gain more respect).
:thumbup:
If you volunteer so many hours at a clinic is there not some kind of loan forgiveness? Also, how many patients would be comfortable being worked on by a H.S. graduate with a technical degree?
 
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Simiam

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But these DHAT/ADHP aren't going to be shoved down our throats... right? I mean if you own your own practice, theyr not going to make you hire a DHAT or ADHP... are they?
Maybe Private Practice owners won't, but I will guarantee you Dental Mills (Western/Delta Dental) who currently feed on International Dentists desperate for work are seeing dollar signs at the thought of DHAT/ADHP.
 
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:thumbup:
If you volunteer so many hours at a clinic is there not some kind of loan forgiveness? Also, how many patients would be comfortable being worked on by a H.S. graduate with a technical degree?
you'll get CE credits for volunteering. different states vary in their allowance for CE from volunteering.
you may get loan forgiveness if you work FT as an emloyee in a community clinic designated as underserved.
 
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:thumbup:
If you volunteer so many hours at a clinic is there not some kind of loan forgiveness? Also, how many patients would be comfortable being worked on by a H.S. graduate with a technical degree?
you'll get CE credits for volunteering. different states vary in their allowance for CE from volunteering.
you may get loan forgiveness if you work FT as an emloyee in a community clinic designated as underserved.

I would not let anyone of DHAT nor ADHP touch my teeth! hell no. I won't even let some dentist touch my teeth even more so with these wannabes.
 

BiomajorPreDent

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You have to have a passion for public service. Period.

Most (not all) of the reasons people go into dentistry, the lifestyle, $, ownership of practice/private business, directly contradict working in a medicaid govt office.

Building more dental schools won't solve this problem because you can practice where ever you want upon graduation.

And these mid level providers will do the same thing. The only way it will help underserved areas is if you mandate where they can practice. You are fooling yourself if you think midlevels will jump for joy and run to the nearest medicaid office.

This midlevel nonsense is all about prestige and the desire for more power/money/status.

I think if there are more financial incentives for dentists to work in public health, then more dentists would do so.

At the end of the day, when new grads have $200k in debt, they will go to where ever they can to pay back the loans.

Not to mention that drilling and filling in these medicaid clinics doesn't do much for clinical skills that need work to begin with 1 year out of graduation.

At the end of the day, it is all about the $. If medicaid clinics were as profitable to dentists as private practice, there would be no underserved populations in this country.
 

Slack3r

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You have to have a passion for public service. Period.

Most (not all) of the reasons people go into dentistry, the lifestyle, $, ownership of practice/private business, directly contradict working in a medicaid govt office.

Building more dental schools won't solve this problem because you can practice where ever you want upon graduation.

And these mid level providers will do the same thing. The only way it will help underserved areas is if you mandate where they can practice. You are fooling yourself if you think midlevels will jump for joy and run to the nearest medicaid office.

This midlevel nonsense is all about prestige and the desire for more power/money/status.

I think if there are more financial incentives for dentists to work in public health, then more dentists would do so.

At the end of the day, when new grads have $200k in debt, they will go to where ever they can to pay back the loans.

Not to mention that drilling and filling in these medicaid clinics doesn't do much for clinical skills that need work to begin with 1 year out of graduation.

At the end of the day, it is all about the $. If medicaid clinics were as profitable to dentists as private practice, there would be no underserved populations in this country.
Welcome to the real world.
 

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Straight from the new healthcare bill
http://dpc.senate.gov/healthreformbill/healthbill52.pdf

Enhancing Health Care Workforce Education and Training.

New support for workforce training programs is established in these areas:
 Family medicine, general internal medicine, general pediatrics, and physician assistantship.
 Rural physicians.
 Direct care workers providing long-term care services and supports.
 General, pediatric, and public health dentistry.
 Alternative dental health care provider.
 

banana23

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The central issue is access to care.

I call on all dentist to volunteer at local community clinics to help alleviate this issue.

I realize many new grads have a ton of debt and dentistry is hard physical work esp at the community clinic setting. BUt if we don't take matters to our own hands it will be taken away from us all in the name of access to care (even though we know the reasons to push for professional advancement for the ADHA is for ego and to gain more respect).

There is no access to care problem, period. Sure there are a lot of people who feel that you should subsidize their care but that is something different. I have spent a lot of time at community health clinics and after working on hundreds of illegal immigrants, iPhone users, and new model Mercedes owners I nor anyone else should have to work for free to stave off midlevel’s. Perhaps instead it’s time to acknowledge the issue for what it really is: discounted/free dental care for those who don't pay taxes.
 

DrJeff

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There is no access to care problem, period. Sure there are a lot of people who feel that you should subsidize their care but that is something different. I have spent a lot of time at community health clinics and after working on hundreds of illegal immigrants, iPhone users, and new model Mercedes owners I nor anyone else should have to work for free to stave off midlevel’s. Perhaps instead it’s time to acknowledge the issue for what it really is: discounted/free dental care for those who don't pay taxes.
+1

Dead on! There isn't an access to care issue as much as there's a personal responsibility issue/sense of entitlement issue
 
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mike3kgt

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+1

Dead on! There isn't an access to care issue as much as there's a personal responsibility issue/sense of entitlement issue
:thumbup: I think it should be DrJeff's personal responsiblity to pay my taxes, healthcare premiums and give me 68.88 a week for food.

That's right folks, I think we should all give in and go on the government plan. If you can't beat 'em, join 'em!
 

DrJeff

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:thumbup: I think it should be DrJeff's personal responsiblity to pay my taxes, healthcare premiums and give me 68.88 a week for food.

That's right folks, I think we should all give in and go on the government plan. If you can't beat 'em, join 'em!
well pay your FULL bill at my office, and then we'll talk ;)