[MASTERY] Can't Put It Back in the Bottle

CAN'T PUT IT BACK IN THE BOTTLE

It's a done deal. Game over. One more stake in the ground. You can add to the new classes of dental professionals California's registered dental assistants who are now enabled to deliver extended services (RDA-EF2). These new dental providers will have the widest scope of functions of any dental assistants in the country.

Starting January 1, this new category of assistants will be able to place all types of restorations - direct and indirect, alloy and composite - and even endodontic points. In short, these RDA-EF2s can do anything a dentist does to restore a tooth except administer anesthesia and remove tooth structure.

A recent report states there are currently 1,400 RDA- EFs in California that can take impressions and place provisional crowns, but not deliver permanent restorations. Two schools in California are offering courses to become an RDA-EF2: the University of California, Los Angeles and Sacramento City College.

The requirements to become one of these midlevel providers, however, will not come easily. To become an RDA, you will have to complete a series of courses and pass an exam. If you then want to add extended functions, you must take an additional 388 hours of instruction and pass an exam. Current RDA-EFs who want to become RDA-EF2s will have to take 280 additional hours and pass an exam.

The scope of dental assistant practices varies dramatically from state to state. Utah, for example, forbids assistants place any type of restoration, whereas Ohio expressly allows most of what the California RDA-EF2s can do, except place endodontic points.

The list of states allowing hygienists to do restorations is longer. According to the American Dental Hygienists' Association, Colorado, New Jersey, and Washington allow hygienists to place temporary crowns and fillings and permanent amalgam and composite resin fillings. Hawaii, Texas, Utah, Louisiana, and Delaware, on the other hand, bar hygienists from all of these procedures. Most other states allow some restorative work, but not all. Several states neither explicitly forbid, nor clearly allow, auxiliaries to perform restorative procedures, leaving their scope of duties open to interpretation.

Dentists in California resisted the notion of midlevel providers until recently. And the CDA stood firmly against this kind of dentistry. But due to the access issue and lack of available dental providers, the CDA caved. Now the CDA has rationalizes their support by saying these RDA-EF2 providers will actually enhance private practices by providing more care and allowing them to make more money. Nice spin. They've created a new definition, "four-handed dentistry," whereby the dentist relies on assistants to do a larger portion of the work they would traditionally do for a fee.

Context is decisive. Disruptive change causes a shift in context. Access to dental care has now been recognized as a public health issue. Access to dental care has move to the political arena. And this public and political declaration is causing a disruptive change.

Once there has been a contextual shift, things can never go back. Personally, I see this as a huge business opportunity. Given that my work is all about educating and coaching dentists to become highly competent leaders, owners and managers of a business enterprise, growing dentists to develop a business that includes midlevel providers is clearly achievable. I currently have a number of clients who own and manage large dental operations as well as number of community clinics on my lines. With my background in corporate consulting, I can envision a number of exciting possibilities.

The biggest problem for the majority of today's practicing dentists will be their weakness as managers. This weakness might explain why most dentists practice solo, why the number of solo practices has remained relatively constant for decades. The solo practice has few people to manage. Dentists like to work with teeth, not people. But it will be those dentists who can master management, allowing dental care to be delivered through others, who will succeed in this new context.

Given that training and developing dentists as effective managers is my primary job, guess I won't be retiring for a few more years.

Dr. Marc B. Cooper
The Mastery Company
MasteryCompany.com

References:

"Lessons Learned: Implications for Workforce Change" by Michael Glick; (JADA 2008;139[3]:232, 234).

Overview of Mid-Level Provider Models by Michael Payne;
http://www.asdanet.org/uploadedFiles/The.../Den tal%20Therapist%20Article.doc

California Dental Association Website;
http://www.cda.org/advocacy_&_the_law/issues_ &_policies/denti-cal_government_programs/

Dr Bicuspid;
http://www.drbicuspid.com/index.aspx?sec=def

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Dr. Marc B. Cooper
President and CEO
The Mastery Company