The medical profession is one in which practice of the profession has for a long time been restricted to people with licenses. Offhand, the question, “Ought we to let incompetent physicians practice?” seems to admit of only a negative answer. But I want to urge that second thought may give pause.

In the first place, licensure is the key to the control that the medical profession can exercise over the number of physicians. To understand why this is so requires some discussion of the structure of the medical profession. The American Medical Association is perhaps the strongest trade union in the United States. The essence of the power of a trade union is its power to restrict the number who may engage in a particular occupation. This restriction may be exercised indirectly by being able to enforce a wage rate higher than would otherwise prevail. If such a wage rate can be enforced, it will reduce the number of people who can get jobs and thus indirectly the number of people pursuing the occupation. This technique of restriction has disadvantages. There is always a dissatisfied fringe of people who are trying to get into the occupation. A trade union is much better off it can limit directly the number of people who enter the occupation-who ever try to get jobs in it. The disgruntled and dissatisfied are excluded at the outset, and the union does not have to worry about them.

The American Medical Association is in this position. It is a trade union that can limit the number of people who can enter. How can it do this? The essential control is at the stage of admission to medical school. The Council on Medical Education and Hospitals of the American Medical Association approves medical schools. In order for a medical school to get and stay on its list of approved schools it has to meet the standards of the Council. The power of the Council has been demonstrated at various times when there has been pressure to reduce numbers. For example, in the 1930’s during the depression, the Council on Medical Education and Hospitals wrote a letter to the various medical schools saying the medical schools were admitting more students than could be given the proper kind of training. In the next year or two, every school reduced the number it was admitting, giving very strong presumptive evidence that the recommendation had some effect. . . .

Control over admission to medical school and later licensure enables the profession to limit entry in two ways. The obvious one is simply by turning down many applicants. The less obvious, but probably far more important one, is by establishing standards for admission and licensure that make entry so difficult as to discourage young people from ever trying to get admission. . . .

In the first place, does [licensure] really raise standards of competence? It is by no means clear that it does raise the standards of competence in the actual practice of the profession for several reasons. In the first place, whenever you establish a block to entry into any field, you establish an incentive to find ways of getting around it, and of course medicine is no exception. The rise of the professions of osteopathy and of chiropractic is not unrelated to the restriction of entry into medicine. On the contrary, each of these represented, to some extent, an attempt to find a way around restriction of entry. Each of these, in turn, is proceeding to get itself licensed, and to impose restrictions. The effect is to create different levels and kinds of practice, to distinguish between what is called medical practice and substitutes such as osteopathy, chiropractic, faith healing and so on. These alternatives may well be of lower quality than medical practice would have been without the restrictions on entry into medicine.

More generally, if the number of physicians is less than it otherwise would be, and if they are fully occupied, as they generally are, this means that there is a smaller total of medical practice by trained physicians-fewer medical man-hours of practice, as it were. The alternative is untrained practice by somebody; it may and in part must be by people who have no professional qualifications at all. Moreover, the situation is much more extreme. If “medical practice” is to be limited to licensed practitioners, it is necessary to define what medical practice is, and featherbedding is not something that is restricted to the railroads. Under the interpretation of the statutes forbidding unauthorized practice of medicine, many things are restricted to licensed physicians that could perfectly well be done by technicians, and other skilled people who do not have a Cadillac medical training. I am not enough of a technician to list the examples at all fully. I only know that those who have looked into the question say that the tendency is to include in “medical practice” a wider and wider range of activities that might well be done by others. The result is to reduce drastically the amount of medical care. The relevant average quality of medical care, if one can at all conceive of the concept, cannot be obtained by simply averaging the quality of care that is given; that would be like judging the effectiveness of a medical treatment by considering only the survivors; one must also allow for the fact that the restrictions reduce the amount of care. The result may well be that the average level of competence in a meaningful sense has been reduced by the restrictions.

Even these comments do not go far enough, because they consider the situation at a point in time and do not allow for changes over time. Advances in any science or field often result from the work of one out of a large number of crackpots and quacks and people who have no standing in the profession. In the medical profession, under present circumstances, it is very difficult to engage in research or experimentation unless you are a member of the profession. If you are a member of the profession and want to stay in good standing in the profession, you are seriously limited in the kind of experimentation you can do. A “faith healer” may be just a quack who is imposing himself on credulous patients, but maybe one in a thousand or in many thousands will produce an important improvement in medicine. There are many different routes to knowledge and learning and the effect to restricting the practice of what is called medicine and defining it as we tend to do to a particular group, who in the main have to conform to the prevailing orthodoxy, is certain to reduce the amount of experimentation that goes on and hence to reduce the rate of growth of knowledge in the area. What is true for the content of medicine is true also for its organization, as has already been suggested. I shall expand further on this point below.

There is still another way in which licensure, and the associated monopoly in the practice of medicine, tend to render standards of practice low. I have already suggested that it renders the average quality of practice low by reducing the number of physicians, by reducing the aggregate number of hours available from trained physicians for more rather than less important tasks, and by reducing the incentive for research and development. It renders it low also by making it much more difficult for private individuals to collect from physicians for malpractice. One of the protections of the individual citizen against incompetence is protection against fraud and the ability to bring suit in the court against malpractice. Some suits are brought, and physicians complain a great deal about how much they have to pay for malpractice insurance. Yet suits for malpractice are fewer and less successful than they would be were it not for the watchful eye of the medical association. It is not easy to get a physician to testify against a fellow physician when he faces the sanction of being denied the right to practice in an “approved” hospital. The testimony generally has to come from members of panels set up by medical associations themselves, always, of course, in the alleged interest of the patients.

When these effects are taken into account, I am myself persuaded that licensure has reduced both the quantity and quality of medical practice; that is has reduced the opportunities available to people who would like to be physicians, forcing them to pursue occupations they regard as less attractive; that it has forced the public to pay more for less satisfactory medical service, and that it has retarded technological development both in medicine itself and in the organization of medical practice. I conclude that licensure should be eliminated as a requirement for the practice of medicine.

When all this is said, many a reader, I suspect, like many a person with whom I have discussed these issues, will say, “But still, how else would I get any evidence on the quality of a physician. Granted all that you say about costs, is not licensure the only way of providing the public with some assurance of at least minimum quality?” The answer is partly that people do not now choose physicians by picking names at random from a list of licensed physicians; partly, that a man’s ability to pass an examination twenty or thirty years earlier is hardly assurance of quality now; hence, licensure is not now the main or even a major source of assurance of at least minimum quality. But the major answer is very different. It is that the question itself reveals the tyranny of the status quo and the poverty of our imagination in fields in which we are laymen, and even in those in which we have some competence, by comparison with the fertility of the market. . . .

The impossibility of any individual or small group conceiving of all the possibilities, let alone evaluating their merits, is the great argument against central governmental planning and against arrangements such as professional monopolies that limit the possibilities of experimentation. On the other side, the great argument for the market is its tolerance of diversity; its ability to utilize a wide range of special knowledge and capacity. It renders special groups impotent to prevent experimentation and permits the customers and not the producers to decide what will serve the customers best.

I am not the one who argued labor value theory; it was Caitlin in her original oped and previous posts. Her entire argument WAS based on a dental therapist providing cheaper care because of less investment in time and money in their education and training.

If you really want to get into modern theoretical theory and if memory serves me Ricardo was explaining a trade advantage in society’s production capacity making widgets or growing apples. I realize economic purists worship at Jevons alter but if we are really going to dissect the market forces, societies desire to access healthcare and those able to provide that health care then the discussion will need to be a little more germane than Nobody’s Daughter or A Time to Kill.

As far as the physician/nurse collaborative agreement, I am very familiar with the statute (RSMO 334) and the rules (20 CSR2150-7.135) which says the collaborating physician must be present at the same site as the physician assistant 66% of the time and within 30 miles the other 34% unless the team has received a waiver from the board of healing arts, those waivers are up to 50 miles but are very specific regarding location and need.

As I said in my very first post, the purpose of the dental board is to protect the public. It is their responsibility to work with all the interested stake holders in any discussion of “new” ideas including; educational requirements, scope of practice and responsibilities, level of supervision, appropriate settings and standards of care. It is their job to evaluate the evidence on an issue—–not extrapolate from a few studies or experiment with some political solution for the public’s health. This is not a new widget thrown out into the market to see if it is successful through market forces, this is health care. If a therapist cannot provide surgical care properly than someone gets hurt, maybe seriously…………is this really what you want the market to decide?

The nurse-practitioner model is one viable option, if that is what works best in the dental model. Perhaps you are not familiar with how that actually works, but the “overseeing” physician in many cases need only be within 50 miles of the office. So the nurse-practitioner essentially is the primary care provider.

If dental therapists cannot do surgical care properly, then they will not provide surgical care because people will not want their services for that.

If consumers have a choice between seeing a dentist and seeing a dental therapist, both operating at the same price, they’ll choose the dentist every time because the dentist has superior training. So, the primary reason that dental therapists would charge less is because they have to.

There’s no way to tell in advance whether dental therapists would be able to survive without the kind of public subsidies you describe, but there’s no reason to artificially prevent them from trying. It’s a decision for consumers to make, not a decision for government officials to make on behalf of consumers. Besides, you’re forgetting about the much bigger subsidy that full-fledged dentists are receiving right now — artificially high incomes through regulatory capture. Licensure rules that disallow dental therapists from practicing are a form of protectionism, and amount to a huge government subsidy on the behalf of dentists. It makes no sense to be concerned about one form of subsidy but not the other.

The reason comparative advantage is the paramount economic consideration at play here is because some dental procedures require less skill than others. Society is always better off if people who have higher skills focus on those high-skilled services while lesser-skilled people undertake the lesser-skilled activities. P.J. O’Rourke explained it in a way that even you should be able to understand:

The implications of division of labor are surprising, but only if we don’t think about them. If we do think about them, they are, like most economic principles, a matter of common sense. There are, however, a few things about economics that don’t seem to make sense at all. Todd G. Buchholz, in his book New Ideas from Dead Economists, says, “An insolent natural scientist once asked a famous economist to name one economic rule that isn’t either obvious or unimportant.” The reply was “Ricardo’s Law of Comparative Advantage.”

The English economist David Ricardo (1772-1823) postulated this: If you can do X better than you can do Z, and there’s a second person who can do Z better than he can do X, but can also do both X and Z better than you can, then an economy should not encourage that second person to do both things. You and he (and society as a whole) will profit more if you each do what you do best.

Let us decide, for the sake of an example, that one legal thriller is equal to one pop song as a Benefit to Society. (One thriller or one song = 1 unit of BS.) John Grisham is a better writer than Courtney Love. John Grisham is also (assuming he plays the comb and wax paper or something) a better musician than Courtney Love. Say John Grisham is 100 times the writer Courtney Love is, and say he’s 10 times the musician. Then say that John Grisham can either write 100 legal thrillers in a year (I’ll bet he can) or compose 50 songs. This would mean that Courtney Love could write either 1 thriller or compose 5 songs in the same period.

If John Grisham spends 50 percent of his time scribbling predictable plots and 50 percent of his time blowing into a kazoo, the result will be 50 thrillers and 25 songs for a total of 75 BS units. If Courtney Love spends 50 percent of her time annoying a word processor and 50 percent of her time making noise in a recording studio, the result will be one half-completed thriller and 2.5 songs for a total of 3 BS. The grand total Benefit to Society will be 78 units.

If John Grisham spends 100 percent of his time inventing dumb adventures for two-dimensional characters and Courtney Love spends 100 percent of her time calling cats, the result will be 100 thrillers and 5 songs for a total Benefit to Society of 105 BS.

(Just to make things more confusing, note that Courtney Love loses 40 percent of her productivity by splitting her time between art and music, while John Grisham loses only 25 percent of his productivity. She has the “comparative advantage” of making music because her opportunity costs will be higher if she doesn’t stick to what she does best.)

David Ricardo applied the Law of Comparative Advantage to questions of foreign trade. The Japanese make better CD players than we do, and they may be able to make better pop music, but we both profit by buying our CDs from Sony and letting Courtney Love tour Japan. And if she stays there, America has a definite advantage.

Comparative advantage is the rare example of the counterintuitive in economics.

Someone who has better training should focus on the specific activities that require that training. Leave the rest to somebody else. Consumers are better off. Dentists are better off. Dental therapists are better off. Society is better off.

If you’re right that the sunk costs of maintaining dental equipment and office space will not allow dental therapists to charge significantly less than dentists, then dental therapy as a profession will die out on its own. Markets are excellent tools for sorting those things out. There’s no reason to keep the status quo regulatory subsidy for full-fledged dentists just because you don’t think dental therapists are a good idea. That’s a matter between consumers and providers.

It’s just a fact that an MD’s time is “more valuable” than a physician’s assistant’s time. (And thus, the cost to see one or the other is significantly different) It is the same for a dentist vs. a dental therapist.

You cannot see past the examples of other countries. Socialized medicine is a completely different disagreement which I’m sure we probably mostly agree on; the issue at stake here is the licensing monopoly that dentists have on the profession in the US. Don’t conflate two separate issues.

As I said before, your argument is like saying I want teachers but since the far left wants teachers too, teachers are bad. It doesn’t mean that the teachers I advocate for can only work in the setting the far left or in the manner that the far left envisions. By all means, my vision is completely different.

I did not suggest that subsidies of the clinics and school settings themselves affect quality of the provider but rather the costs of providing the services in a socialized health care system like New Zealand or the UK are less because of the governments willingness to spend the citizens tax dollars for infrastructure and the daily costs of doing business.

I find your statement ” Overhead is a fixed cost, but a dental therapist’s time is not as valuable as a dentist’s, and thus !she! can charge slightly less” rather disturbing and certainly sexist.
To suggest that anyone’s time is less valuable when providing direct health care to a patient is a dangerous precident to propose.

I also question your suggestion “it is easier to get dental therapists (as opposed to dentists) to rural areas where there is a need for dental care” as purely speculative. This statement is again one of the talking points for those people who seek to change our entire system of delivering heath care.

It is obvious from your statements that you really do not understand the political forces you are dealing with here. The free market is NOT at play but rather the first step to a socialized conversion. Now if you would like to argue that the citizens of our great state should be given the choice between government run and subsidised care as opposed to private free market access to the system than fine—let us have that discussion. But to try and dress this issue up as some sort of “comparative advantage” based on cost of education or the “lesser value” of a persons time and skill is just plain ludicrous.

And the subsidies do not affect the quality, that’s just fallacious reasoning. Comparative advantage is at play here. Overhead is a fixed cost, but a dental therapist’s time is not as valuable as a dentist’s, and thus she can charge slightly less. Plus, it is easier to get dental therapists (as opposed to dentists) to rural areas where there is a need for dental care.

Why not let the market decide whether individuals prefer dental therapists or dentists? The numerous studies show that there is not a safety issue.

The REAL reason DHATs can provide possibly equal services (I am not yet willing to concede the point) is because they are heavily subsidized—usually through government expenditure or benevolent grants. Take the case of New Zealand or UK–yes they do provide needed services but they are doing it in schools and public clinics–the typical overhead costs are the burden of goverment. Alaska’s DHATs basicly work for the govenment through the Tribal Council. The MN expanded hygiene provider will most undoubtably work in a federal, state or local public health clinic, agian subsidized through higher taxes. I belive in all 53 countries which have some form of DHAT the real competitve advantage belongs NOT with your hypothisis of lesser cost through lesser education but rather with the power of the government and their largess with our tax dollars.

The economic principle at work here is comparative advantage. Some dental services require more specialized training and skills in order to be undertaken successfully. Dentists have a comparative advantage in providing those services, so the need for dentists will not disappear no matter how many dental therapists penetrate the market.

Other dental services do not require nearly as much specialized training and skills. Dental therapists have a comparative advantage in providing those services, because their lack of advanced training in providing more specialized services makes their time less valuable — not necessarily always in specific unique cases, but certainly in a general aggregate sense. They can therefore afford to charge less money than a full-fledged dentist would, for the limited range of dental services they provide.

After looking at the research on the work of dental therapists, I am satisfied that they can provide a much-needed service at an appropriate level of quality. I would never argue that someone should be forced to go to a dental therapist over a dentist, but I do believe they should be afforded that opportunity.

You wrote:

The “barriers” placed by the legislature and enforced through licenseing boards serve only one purpose—to protect the welfare of the public. One part of that responsibility to protect the citizenry from ill informed and poorly concieved politically based “solutions”.

The intention behind the “barriers” may be to protect the public, but they have another purpose and effect — they protect dentists from competition. The peer-reviewed literature shows a similar quality of work between a dental therapist and a dentist. What protection has this law provided the public then, other than to prevent people from obtaining dental care? (With which studies in particular do you take issue? I cited a number number of studies with positive conclusions about dental therapists. I cannot address any flaws in the literature without knowing which ones with which you disagree.)

The second part of that quote about political solutions (which does not actually follow from your previous statement, but I’ll address it anyway) is in no way hindered by licensing laws. If you disagree with political solutions — I personally do not think the government should make health care decisions for the public either — then you disagree with that component. Right now, our tiered system is a dentist or no dental care (and many are opting for no dental care.) An argument to open the health care market by removing regulations should not be clouded by an entirely different argument against government control of health care.

A market does not provide a homogenous set of goods. In the market place, I can choose to buy my dinner at McDonald’s, or I can buy it at Morton’s Steakhouse(or any other restaurant/grocery store.) The quality is higher at Morton’s, but I may be satisfied with McDonald’s because I cannot afford an expensive restaurant and McDonald’s satiates my hunger just as well.

The licensing law prohibits that decision, leaving consumers with only the Morton’s of dentistry. People choose to forego dental care altogether because of its high price. How is that a good thing?

Dental therapists still undergo training, just less of it. When a person visits a dentist, the majority of the visit is spent with a dental hygenist and not a dentist. A dental therapist can offer a similar product for a lower price — which opens the market for more people to receive dental care. The licensing laws price consumers out without protecting them.

Just because someone on the left (for different reasons and intentions) sees the value of dental therapists, it does not mean that we should prohibit them. Let the market and the public choose which product they want, whether it’s where they choose to eat, or who they let clean their teeth.