Hooked on Oral Health for Michigan’s Underserved

Part One
At the end of another long but satisfying day in Dental Clinic North’s (DCN) Cadillac, Michigan site, Benjamin Fishman, D.D.S., is pinning up another crayoned work of art in his growing gallery. Carefully etched in blue and purple, the words read, “You’re the light that shines so bright. Thanks for making our smile better.” For this NHSC clinician, working primarily with the underserved and uninsured of northwest Michigan, there is no greater reward than the simple eloquence and creative hand of a smiling child.

An action-packed day for Fishman can include restorative/emergency treatment on 10 to 15 patients and initial exams on 10 more. His patients are primarily children from families on Medicaid or with no insurance at all. “We often schedule an hour for each patient and then try to do as much work as possible in that time,” says Fishman. “Many times they don’t return, so my goal is to make sure they leave my chair with as much work completed as possible.” This strategy is particularly important with his pediatric patients whose overall health and future quality of life might suffer irreversible harm without his intervention.

At the Cadillac clinic, Fishman is one of two dentists, including Dr. Scott Trapp, an NHSC Ready Responder (to read more about Dr. Trapp, visit: http://nhsc.bhpr.hrsa.gov/about/success_stories/mi.asp). For Fishman, Trapp has been instrumental in bridging the gap between novice decision making and that of an experienced clinician. The clinic includes one dental hygienist, three dental assistants, and one office manager.

Fishman is proud to point out that one innovative program his clinic offers is outpatient treatment in a local hospital setting under general anesthesia. Since coming on board in July 2004, Fishman has become credentialed—by way of Trapp’s instruction—to provide these services to children with extensive tooth decay and patients with compromised mental capacities. According to Fishman, only a handful of dentists provide this service, and it is something uniquely offered to the underserved by DCN. In fact, in 2003, prior to his arrival, DCN was able to offer outpatient hospital services to 200 underserved special-needs patients.

Reflecting on what brought him to his career and serving the needy in Michigan, Fishman recounts that his interest in dentistry “was sparked by a chance conversation while I was waiting tables in Traverse City during my college years.” As the story goes, in the course of that conversation, Dr. Vincent Mack, a local dentist, took the time to describe what his profession entailed and then invited Fishman to observe him at his clinic. After returning to Mack’s clinic for three consecutive summers, Fishman was accepted into the University of Michigan’s (UM) School of Dentistry in August 2000.

While Fishman began his academic career with Mack’s private practice model in mind, this was soon to change under the influence of the UM School of Dentistry’s Community Outreach Program. The program requires all senior dental students to work with the underserved in a number of Michigan venues, including DCN’s Traverse City Clinic. Working as a student dentist with the migrant farm workers program in the summer of 2003 was the spark that ignited Fishman’s already smoldering passion for making a fundamental difference in the lives of those in need.

It is no coincidence that Tom Veryser, D.D.S., an NHSC Ambassador for UM School of Dentistry, was the outreach program’s inspired assistant dean. And it was only natural that he advised Fishman to explore the NHSC Loan Repayment Program (LRP) as a means to fulfill his goal of working with Michigan’s needy at 1 of DCN’s 9 (out of 10) HPSA-designated clinics after graduation. When Veryser joined DCN as dental director in January 2004, Fishman was even more convinced that he would find a perfect professional home within a system that included the leadership of his former advisor. “Dr. Fishman is all one could ever hope for in a recent dental graduate,” says Veryser. Together, they now share their enthusiasm for public health dentistry with new generations of UM dental students in the clinic and university venues.

While Fishman is the first to admit that he never envisioned himself working where he is today, he enthusiastically recommends his path to other dental students. “Here, you are free to focus on the dentistry and not worry about things like payroll, liability, and office management,” he says. To him, developing proficiency and efficiency, especially in areas such as endodontics and oral surgery—seldom seen in private practice or as a student—are the end results of choosing public health dentistry. But ultimately, there is no greater satisfaction than knowing that his efforts can change the future and breathe hope into the lives of those he serves.

Whether he chooses to stay with DCN or go on to establish his own practice, Fishman resolutely states that he will always be there for those who need him the most. “Each and every person counts,” he says. “And if people are healthy, they, too, will go out and make an impact on others.” And for this NHSC clinician, helping make America a healthier place is the best goal that anyone could hope to achieve.

Part Two
Nestled in Michigan’s lower northwest counties are the clinics and outpatient hospital sites of Dental Clinics North (DCN), one of the Nation’s understated oral health care success stories. Statistics paint the big picture—since its inception in 1999, the system has gone from serving 6,000 Medicaid or uninsured clients in 5 clinics to serving more than 20,000 patients in 10 clinics, as well as 3 hospital sites spread throughout a 26 county region. But what’s really impressive is the difference in the quality of life and prospects for the future that DCN’s dedicated band of 68 workers has made in the countless lives of Michigan’s underserved and uninsured.

Deeply interwoven within the fabric of DCN is the National Health Service Corps (NHSC). Of the 10 clinics in the system, nine are Federally-designated health professional shortage areas (HPSAs) that are registered as NHSC-eligible sites. Seven of the 9 NHSC-eligible sites have benefited from or currently employ NHSC clinicians. The Traverse City clinic, the only non NHSC-eligible site, provides a vital proving ground in public health dentistry for all third-year dental students from the University of Michigan (UM) School of Dentistry. And of the many students who have embarked on careers with the underserved because of their experience with DCN and other clinics, many have joined the ranks of the NHSC through its Loan Repayment Program (LRP).

Tom Veryser, D.D.S., the current dental director of the DCN system, is also an adjunct professor at UM and continues in his role as an NHSC Ambassador to UM’s School of Dentistry. As recently as December 2004, Veryser met with a third year student to show her what public health dentistry was all about so she could decide if the NHSC LRP would suit her future plans. Two of the three current NHSC clinicians, Scott Trapp, D.D.S (Ready Responder), and Benjamin Fishman, D.D.S. (Loan Repayor), work at the Cadillac, Michigan clinic. Scott Babin, D.D.S. (Loan Repayor), is located at DCN’s Manistee, Michigan site.

As a former assistant dean at UM, Veryser understands and anticipates the needs of new dentists by pairing them with experienced mentors. For Fishman, working alongside Scott Trapp has created a synergy with results that translate directly into healthy futures for his patients. “Working with a seasoned dentist fosters continual learning, and allows a new dentist to take healthy risks in decision making and treatment planning,” says Fishman. Since his arrival in July 2004, Fishman has had the opportunity to become credentialed—under Trapp’s instruction—to handle special needs cases in a hospital outpatient setting.

Linda Yaroch, R.N., M.P.H., has worked in public health for most of her professional career and has been involved with DCN as administrative director from the beginning. “The daily reality for children with untreated oral disease includes persistent pain, inability to eat comfortably, embarrassment at discolored and damaged teeth, and distraction from play and learning,” says Yaroch. As such, the State of Michigan currently covers dental treatment for children in its Medicaid budget. However, in an attempt to balance the overall budget in increasingly difficult times, the State has reluctantly eliminated dental Medicaid benefits for adults.

In light of this new reality, DCN’s goal is to serve at least 70 percent of Michigan’s adults and children who would otherwise go without treatment. For DCN clinicians and their support staff, meeting this goal means tackling rampant pediatric and adult oral disease one patient at a time.

For the DCN team, it is just as critical to provide quality access to dental services for adults as it is for children, because they are the ones who ultimately determine the status of their children’s oral health. Consequently, DCN initiated its “Northern Dental Plan” in April 2004 to cover uninsured low-income adults living at or below 200 percent of the Federal Poverty Guidelines. A $50 enrollment fee entitles each “member” to an initial comprehensive oral exam with full-mouth radiographs and treatment plans based on medical need and their ability to pay. According to Veryser, fees for treatment cover DCN’s base service costs and are 30 to 40 percent below what is typically charged in private practice. “So far, around 1,000 people have enrolled, but we are hoping that the plan will one day represent a third of our clinics’ activities,” he says. While he acknowledges that DCN’s efforts to provide access will never replace Medicaid coverage for adults, it does bring good oral health one step closer for Michigan’s needy populations. It may even offset some of the pressure on hospital emergency rooms that are obliged to treat oral disease when it becomes a medical emergency.

In plotting the future of the DCN system, both Yaroch and Veryser readily point to the involvement of NHSC programs and clinicians as a key factor to their success. “NHSC provides us the opportunity to recruit new grads who might otherwise seek positions in the private sector,” says Veryser.

Learn about other NHSC success stories.