Hamilton AI (1977), Expanded Duties: An Economic Fallacy, Operative Dentistry, 2(1) 1-2.

Expanded Duties: An Economic Fallacy

Increased productivity and lower prices are worthy aims for any economy. Over the years industry has adopted various methods to achieve these objectives. Dentistry, though a profession, is no less obliged to do likewise.

Recently it has been recommended that some of the tasks of operative dentistry, such as placing and finishing restorations of amalgam and composite resin, be assigned to dental auxiliary personnel, with the idea that this will increase productivity and lower costs. The proponents of expanded duties-mainly government employees and academics-already have spent enormous sums of money to demonstrate that dental assistants and hygienists can in fact learn to perform these operations. Much of this research, however, was unnecessary because it had already been shown, in the 1920s in New Zealand and in the 1960s in Britain, that within a period of two years young women can be taught to give prophylaxes, prepare cavities, place restorations of amalgam and silicate, extract teeth for children, and provide education for patients. Moreover, the quality of the treatment has been shown to compare favorably with that provided by dentists. This information was readily available and, had it been consulted, much costly research could have been avoided.

Having demonstrated to their own satisfaction that auxiliaries could learn to perform the dental tasks assigned to them, the proponents of the scheme began at once to campaign vigorously for its implementation-almost, it seemed, on the maxim that because it can be done it should be done. We need only remind ourselves that we can also jump off the Space Needle to see the fallacy in this kind of argument. To make it legal for dental auxiliaries to treat patients, state dental asso9iations were pressured and intimidated to change the legal acts governing the practice of dentistry. Those state officials with little courage and less foresight capitulated in the name of progress and supported the requested changes; as a result, in some states dental auxiliaries may now provide some forms of treatment for patients.

To support the contention that a system of expanded duties for dental auxiliaries will reduce the cost of providing dental service, the costs of educating a dentist and an auxiliary have been compared. We are told that the cost of educating a dentist, including four years of predental education, is about $60,000, whereas the cost of educating a dental auxiliary is about $8,000. The difference in these costs is advanced as the reason for the cost of treatment being less when it is provided by an auxiliary. An important element, however, is missing from the calculations, and that is the comparable working life of the dentist and the auxiliary. A dentist, graduating in his early twenties and retiring in his sixties, works about forty years. The cost of his education distributed over his working life is about $1,500 per year. Information on the working life of a dental auxiliary is not plentiful but an average of four years would probably be a generous estimate, making the cost of education about $2,000 per year of working life. The estimated cost of a dental education may be comparatively high because it includes four years of predental education, not all of which is required. On the other hand, the estimated cost of educating a dental auxiliary may be comparatively low because in support of programs such as this, costs tend to be underestimated just as benefits tend to be overestimated. Add to this the further training that is often required to adapt to a particular dental practice and the cost of educating dental auxiliaries could well be double the cost of educating dentists. Some saving!

Even more important is the difference

between the two in the scope of their training. The more diverse skill of the dentist, compared with the limited repertoire of the auxiliary, enables him to treat the patient as a whole, that is, comprehensively. This is immensely important because there is a tendency for the specialized worker to acquire a narrow view of the overall purpose of his task, as was recognized by Adam Smith, the first to describe the advantages of the division of labor. It is a tribute to Smith’s foresight that he was also able to predict other disadvantages of the division of labor, namely, overspecialization and the monotony of doing simple repetitive operations. The specialized worker doing his specific task on the assembly line played a crucial part in the Industrial Revolution of the eighteenth century. Within the last three decades, however, there has been a marked departure in the course of industrialization. The continuing desire for greater efficiency and the need to reduce the costly labor component have led to the introduction of automation and this, in turn, has engendered the Second Industrial Revolution.

For dentistry this means we should be looking to new technology as our expanded auxiliary. Future techniques of automation, such as milling devices controlled automatically and programmed to prepare several cavities simultaneously and perhaps allow the preparation of cavities for more than one patient at a time, would enable dentists to increase productivity substantially. At the same time the comprehensive service that comes from our education and experience as professionals would be preserved.

In the final analysis, there are humans attached to teeth, and, in any event, human beings are not machines. They deserve better than task-oriented, assembly-line treatment. To reduce a particular operation, such as the placement of a silver amalgam, to its component parts and have a dental auxiliary complete part of this operation, the insertion of the amalgam, for example, is just such an assembly-line process. While this type of system might have worked well in the eighteenth century, it is not appropriate in the Age of Automation.

The spurious economics used to support expanded duties for dental auxiliaries, foisted on the dental profession by those who couldn’t tell a demand curve from a knuckle ball, should be rejected. The government should abandon these worthless projects on which it is wasting huge sums of the taxpayers’ money. Instead the government should give more support to the teaching of operative dentistry to dental students. Good teachers of operative dentistry are scarce and should not be wasted on teaching auxiliaries whose working life is short, especially as so much needs to be done to improve the competence of dental students who will be spending a lifetime in their chosen profession. It is by graduating dentists that are better trained in operative dentistry that we can provide a better service for the patient. IAN HAMILTON