A Conversation with Bruce Baum, DMD, PhD; Chief, Gene Transfer Section, Gene Therapy and Therapeutics Branch National Institute of Dental and Craniofacial Research, National Institutes of Health.
In a January 2007 commentary in the Journal of the American Dental Association (JADA), entitled "Inadequate Training in the Biological Sciences and Medicine for Dental Students: An Impending Crisis for Dentistry," Dr. Baum argues that the future of dentistry as a respected and integral healthcare profession depends on dental students learning enough medicine to treat the growing numbers of older Americans who have chronic systemic illnesses. If dental schools do not move in this direction, he contends, the profession will become selfmarginalized. To prevent this outcome, Dr. Baum proposes that dental schools mandate a short substantive training experience in general internal medicine. In the conversation that follows, Dr. Baum elaborates on his thesis.
Global Health Nexus (GHN): Given existing demographic trends, plus the fact that it’s been more than 10 years since the Institute of Medicine (IOM) report declared that "Linkages between dentistry and medicine are insufficient to prepare students for a growing volume of patients with more medically complex problems and an increase in medically oriented strategies for prevention, diagnosis, and treatment," why is there still no minimum requirement for dental students to train in general medicine?
Dr. Baum: There are three basic reasons. First, inertia; it’s easier to do nothing. Second, these are good times financially for dentistry, so dentists tend to be happy with the way things are. Third and most important, there is real angst over change. All professions, not just dentistry, tend to be conservative, to resist change. Society grants special privileges to professionals, who, in turn, want to preserve those privileges by preserving the status quo.
GHN: What does the lack of medical training say about the ability of recent dental graduates to care for increasing numbers of older dental patients with significant medical problems?
Dr. Baum: It says that they may be unable to care for such patients in an ideal way unless there is some remediation. There are plenty of competent practitioners who can manage medicallycompromised individuals. But as a generalization, it raises concerns. The issue of medical training for dental students is basically a matter of ensuring dentistry’s relevance. Today, more than eight decades after the publication of the Gies Report in 1926, very little has changed in the overall dental curriculum. I am convinced that dentistry’s ability to remain relevant depends on dentists being able to understand enough general medicine to provide quality dental care to medically compromised people. It would be good for patients and good for dentistry.
GHN: The model of medical training that you propose for dental students is that of a thirdyear medical student. Why did you choose that model and, in practical terms, how would it fit into the dental curriculum?
Dr. Baum: I chose that model because I believe it would be the easiest to fit into the curriculum. Indeed, only minimal additional course work would be needed—a course in physical diagnosis and maybe one in the biology of the major medical diseases, including diabetes, hypertension, and cardiac disease. Thereafter, students would spend a threemonth rotation in general internal medicine functioning as a thirdyear medical student. The additional course work would be taken before the third year and the rotations spaced out over the curriculum, beginning anytime after the end of the second year of study and continuing through the senior year. However, there are many ways that internal medicine training could be accomplished—what’s necessary is that dental schools do something to address this educational shortcoming and then undertake high quality pedagogical research to evaluate the results of their efforts. Right now, this is not happening.
GHN: As you know, in fall 2005, the NYU College of Dentistry entered into an alliance that created the NYU College of Nursing at the College of Dentistry. Although both nursing and dentistry at NYU continue to pursue independent academic agendas, the alliance has resulted in increased opportunities to improve health care.
One way in which this is occurring is through the establishment of a Nurse Practitioner Clinic housed at NYUCD to expand access to both general health care and dental care under one roof. Nurse Practitioner faculty and students work sidebyside with dental faculty and students to assess a patient’s medical status and suitability for dental treatment. This also allows dental students to develop a more comprehensive understanding of patients’ needs as they relate to oral health, and to work collaboratively with nurses to seize opportunities for early disease detection, intervention, and referral.
What are your thoughts on the value of this type of model as a means of enabling future dentists to care for greater numbers of ambulatory elderly patients who have significant medical conditions?
Dr. Baum: In general, I think it’s a very good idea. First, it has the potential to broaden the way the public understands dental care, because it signifies to someone walking into a school of dentistry that they have the opportunity to get more than their teeth treated. Also, it has great potential for expanding the scope of dental practice. If NYU trains dental students to work with nurse practitioners, NYU graduates with large practices might find it advantageous to have a fully based nurse practitioner. This would greatly expand the scope of the practice and greatly help the dentist to manage older and medicallycompromised patients.
GHN: What are your thoughts on the new dual degree—DMD/MD—program recently introduced at Case Western Reserve University School of Dental Medicine?
Dr. Baum: I don’t really know very much about the program except that it exists. For some individuals, I would imagine that it would be very good, especially for oral surgeons and oral medicine practitioners. But it’s not for everybody. I don’t think it’s necessary for the overwhelming majority of dentists. I think you can practice high quality general dentistry having had focused and practical training in general medicine, absent the MD degree.
GHN: What exactly do you think will happen unless there is a major course correction by U.S. dental schools to provide training that enables most general dentists to offer care to patients with complex medical conditions?
Dr. Baum: I think that unless practical training in general internal medicine becomes a core competency for dental students, certain specialties of medicine will take over portions of oral health care. I can envision pediatrics taking over pediatric dentistry; ENT taking over oral surgery;and gastroenterology and dermatology taking over oral medicine. Moreover, because medicine, unlike dentistry, is very good at utilizing auxiliaries, I wouldn’t be surprised if physicians started training auxiliaries to become oral health assistants capable of performing simple operative dentistry procedures. For example, plastic surgeons could train and utilize people to perform a certain level of operative dental care. This could be similar to the successful New Zealand model of using dental nurses to provide routine dental care to the country’s children from 2 to 13 years of age, who would not otherwise have access to essential dental care. Although the dental nurse provides dental care with very little direct supervision, statistics over the past 50 years show that the program is meeting most of the dental needs of the children.
The bottom line is that I am a great believer in universal health care, and the key thing to keep in mind is that healthcare providers exist to serve the public—whatever is best for the public should guide the course of healthcare practice. If dentistry doesn’t change to meet the changing needs of society, medicine could take over portions of oral health care.
GHN: You note that one reason that dental students are not provided with substantive general internal medicine training is because entrenched interests resist change. So until there is a critical mass of dentists trained in general internal medicine who can be groomed to become educators, what intermediate steps can dental schools take to overcome faculty resistance to this new direction?
Dr. Baum: I think that the most important thing dental schools can do is provide significant continuing education (CE) courses for both full and parttime faculty in medicine, modern biology, and major medical concerns for ambulatory dental patients. This is something that would also benefit their own practices. Dentistry is losing ground day by day. We can’t afford to wait until a new generation of medically trained dentists emerges. In the interim, it is easier to address faculty CE needs. But I also think it is time for organized dentistry and the dental education community to take the long view—to take a hard look at where dentistry wants to be in 2030, and to design comprehensive curricula to achieve that goal. Let’s provide current dental students with the best tools to enable them to provide optimal care for middleaged and elderly patients who are medically compromised.
GHN: How do you think this will play out?
Dr. Baum: It will take one or two schools to show that you can provide enough training to make dentists cognizant of medical problems so that they can best treat their patients. And to show that it can be done without incorporating a medical degree. Spending on dental care in the U.S. represents five percent of all healthcare dollars. It’s clear to me that the societal benefits of moving in this direction are worth the modest effort it will take to maintain dentistry as a viable, independent profession.
GHN: Have you received any feedback on your JADA commentary? If so, what has it been?
Dr. Baum: Yes, I have already received emails or letters from about 25 individuals concerning my JADA commentary. All but one of these were very positive and in agreement with the need to provide dental students with training in general internal medicine.