Dr. Bruce Lobitz, an attending physician in the emergency department at Upstate Carolina Medical Center in Gaffney, S.C., sees about 10 patients a week complaining of toothaches. “The bane of our existence,” he calls them.

It’s not just that doctors like him lack the training and tools to solve their dental problems. Many of these patients, he fears, complain of tooth pain simply as a ruse to get prescriptions for narcotics.

“Almost all dental patients request a prescription for narcotic pain pills,” Dr. Lobitz said. “ ‘I just need something to tide me over until I can see a dentist’ — that’s the classic line.” Sometimes, drug-seekers will show their cards: “They’ll say they’re allergic to everything except Vicodin.”

Dental patients — mostly uninsured or indigent — are not unusual in hospital emergency rooms. Poor patients may forgo preventive care and delay treatment until they face a medical crisis. In many states, adult dental benefits under Medicaid, the government insurance program for the poor, have been scaled back or eliminated. And dentists often don’t accept Medicaid patients.

But emergency physicians like Dr. Lobitz cannot know whether someone who claims to be in agony from dental issues is telling the truth — or simply plans, he said, to “go to the next emergency room, next town over, and get another 30 Vicodin.”

Dr. Gail D’Onofrio, chairwoman of the emergency medicine department at Yale School of Medicine, has studied alcohol and drug abuse in emergency rooms. “The overuse of narcotics is a huge problem, and when a patient presents, especially for dental pain, it’s difficult to make an objective assessment,” she said. “It puts the physician in a difficult situation to assess whether or not someone truly needs pain medications. We err on the side of treating pain, and it is a huge potential for abuse.”

The frequent prescription of narcotics in emergency departments for dental pain has been quantified for the first time by research financed by the National Institutes of Health, bringing to light another way opioids get into circulation and contribute to the rampant abuse of painkillers in the United States.

From 1997 to 2007, painkillers were prescribed in three of four visits to the emergency department for dental complaints; roughly half of visits resulted in a prescription for antibiotics, according to a new analysis of the National Hospital Ambulatory Medical Care Survey by Dr. Christopher Okunseri, a practicing dentist and an associate professor of public health at the Marquette University School of Dentistry in Milwaukee.

Over that period, the number of painkiller prescriptions for dental patients in emergency departments rose 26 percent, and antibiotic prescriptions jumped 41 percent, according to the report, published online in January in the journal Medical Care.

“E.D. doctors don’t have the training or expertise to provide definitive care, so the easy way out for them is medication,” Dr. Okunseri said. “If you’re not careful, you’ll create more addicts.”

In interviews, many emergency department doctors acknowledged that they write plenty of prescriptions for opioids for patients complaining of dental pain, but they feel they face a conundrum. “I admit that some people get drugs out of me who shouldn’t get them,” said Dr. Tom Benzoni, an emergency physician who has worked for 18 years at Mercy Medical Center in Sioux City, Iowa.

Yet some patients are genuinely in pain. “Do I deny them drugs so that one person doesn’t get a little more Vicodin?” he said. “It’s emptying the ocean with a teacup to try to address our societal drug problem.”

Time pressures and heavy patient loads leave doctors with few choices. “If your goal is to get people out of the emergency room, it’s about stabilizing and shipping out,” said Dr. Nathaniel Katz, the director of the nonprofit Program on Opioid Risk Management at the Tufts Health Care Institute. “What’s the easiest way to get patients shipped out? Write them a prescription for Vicodin. How long does that take?”

Dr. Katz, a neurologist and pain specialist, added that emergency department doctors lack the tools, like dental X-ray machines, to determine whether, for example, a tooth’s nerve is infected, an excruciating problem that often requires root canal or extraction.

Relatively few emergency department workers are trained to give dental blocks, local anesthetic injections that offer immediate relief for 6 to 16 hours. In theory, the injections reduce the number of dental patients who leave the emergency room with potentially habit-forming narcotics.

Dr. Rita K. Cydulka, the vice chairwoman of the emergency medicine department at MetroHealth Medical Center in Cleveland, offers dental blocks, but she said that others in her specialty don’t want to take the time. “They find it easier to write a script for antibiotics and painkillers, and send people on their way,” she said.

Before writing a prescription, few emergency doctors use drug-monitoring programs to see whether patients have recently been given painkillers. Forty states have these programs and eight have enacted legislation to create them, said John Eadie, director of the Prescription Monitoring Program Center of Excellence at Brandeis University.

“Unfortunately many emergency physicians don’t realize the importance of a quick check of the database to see how many painkiller prescriptions a patient has filled lately,” he said.

During the first half of 2010, just one of 12 monitoring programs that reported to the Center for Excellence had 100 percent of prescribers registered to use their data. In the other states, the percentage of prescribers registered was only 9 percent to 39 percent, Mr. Eadie said.

Some doctors say the many pressures they face create other incentives to quickly prescribe remedies for patients complaining of severe pain. For example, doctors are often rated by their hospitals with patient-satisfaction surveys for how they treat pain.

“You can be faulted for not treating a patient’s pain — it’s considered the ‘fifth vital sign,’ ” said Dr. Abhi Mehrotra, the assistant director of the emergency medicine department at the University of North Carolina Hospitals. “We have to ask a patient’s pain, on a scale of 0 to 10, as well as document a reassessment of their pain after treatment.”

Dr. Benzoni, who is routinely rated on patient satisfaction and sometimes asked by management to explain a bad review, said that he feels at times as if he faces a no-win choice. “If you’re going to criticize me for not giving out narcotics, and you never praise me for correctly identifying a drug-seeker,” he said, “then I’m going to give out narcotics.”

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Enlarge Tovia Smith/NPR

Wellesley College English professor Yoon Lee teaches a class on the rise of the novel.

Tovia Smith/NPR

Wellesley College English professor Yoon Lee teaches a class on the rise of the novel.

As high school seniors wrestle with big decisions before Tuesday’s deadline about which college they want to go to, some of the nation’s top liberal arts colleges are dealing with big decisions of their own. Many of the most elite private schools are trying to figure out how they may have to adapt at a time when they’re seen as a more expensive — and less direct — path to landing a job.

Liberal arts schools have long had a rap of being a kind of luxury, where learning is for learning’s sake, and not because understanding Aristotle will come in handy on the job one day. But economic pressures and changes in the world of higher education have now put them more on the defensive than ever.

“There’s been a lot of hand-wringing for a long time about the relevance of a liberal arts education, but I think those worries have heightened over the last couple years,” says Bowdoin President Barry Mills.

There’s been a lot of hand-wringing for a long time about the relevance of a liberal arts education, but I think those worries have heightened over the last couple years.

- Barry Mills, Bowdoin College President

The worries are both existential and financial — even the most wealthy and well-established liberal arts schools are concerned about how they can afford to keep offering the same small, intimate classroom experience, and low faculty-student ratios that they are known for.

At Wellesley College, for example, an English lit class, where just a dozen students can hash out the character development in a novel, is typical. Even a macroeconomics class has just six students and plenty of discussion.

But it is by definition, enormously expensive. More than two-thirds of Wellesley’s budget goes to faculty, and schools like Wellesley can’t just increase efficiency by making classes bigger or putting lectures online.

“There is a fairly widespread anxiety about the financial viability of our model. The personalized, very labor-intensive instruction that we offer, the rising tuition that will be hard to sustain in the future,” says Wellesley Provost Andy Shennan. “I don’t think anybody is complacent about that issue.”

“We don’t want to stop being who we are,” says Williams College President Adam Falk. As he sees it, technology may offer opportunities — for example, allowing colleges to collaborate with other campuses to offer a more specialized course — but he says it won’t actually offer savings. He points to research done recently by William and Mary College economists David Feldman and Robert Archibald suggesting that liberal arts colleges are kind of like the dentist.

“They show that it’s very, very similar,” Falk says. “You can’t get dental services without going to a dentist. And that dentist can’t be replaced by computer, that dentist can’t do two people at once. Technology has made dentistry much, much better, but it hasn’t changed the cost of dentistry.”

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Some top-tier liberal arts schools, however, who are now feeling the pressure, are starting to challenge that conventional wisdom. As other colleges and universities have already done, they are starting to experiment with putting some lectures online. Vassar College, for example, will soon start posting lectures in just a handful of intro level classes.

“Some of tests suggest that a faculty member can accomplish the same objectives in less time, so that means that they could teach more students in a given semester without sacrificing quality,” Vassar President Catharine Hill says.

The growing cost of financial aid is also a big concern. These elite schools typically have more kids on campus with grants and loans than those paying full sticker price, so colleges end up collecting just about half what they charge. Even schools with big endowments worry about how they can afford to keep offering such discounts. But with liberal arts schools insisting that diversity is as important to the educational experience they offer, they also can’t afford not to.

“It’s a terrible pressure, because our commitment is to access from every economic walk of life,” Falk says.

On top of it all, liberal arts colleges are spending more time and money responding to parents’ concerns about how their little philosophy majors will ever be able to land a job.

“There’s a joke around here that a lot of our students double major,” Shennan says. “They have one major for their parents, and one for themselves.”

At Wellesley, as at most liberal arts colleges, campus tours focus heavily on how the school helps students find internships, and eventually paying jobs. Wellesley is also adapting by adding a class in public speaking, for example — a little more pre-professional than liberal-artsy. Other colleges are adding new majors, such as business, but that may be more about packaging than content.

There’s a joke around here that a lot of our students double major. They have one major for their parents, and one for themselves.

- Andy Shennan, Wellesley College Provost

Shennan says a liberal arts education that teaches kids lifelong skills of how to think and how be adaptable in whatever job they end up doing is actually more important now than ever.

“We are not giving up in any way on the basic beliefs that we have about the long-term value of a liberal arts education,” Shennan says. “But we also don’t have our heads in the sand, and I think we have to continue to make the case as persuasively as we can.”

Sometimes that just means connecting the dots for parents. Most of the top liberal arts schools are now highlighting on their websites, in mailings, in person — any way they can — all their happy stories of alumni who are gainfully employed.

“You can call it marketing, but that’s not the way I think about it. I think about what we’re doing as, we’re educating,” says Bowdoin president Mills. “We point to our alumni and we can show people, here is a guy who is one of the leading technology innovators. Here is a guy who runs a global company. Here is a guy who was the ambassador to Poland and Korea, and then people say ‘Yeah, I get it.’”

For these elite colleges, the challenge is to get parents to focus on the return on investment more than price.

Indeed, in the world of the most prestigious liberal arts schools, price is also a point of pride, and a factor in college rankings. No one is driving up costs to move up a rank on U.S. News and World Report, Mills says, but when spending per student is seen as an indicator of quality, none of these elite schools want to be known for being cheap either.

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KANSAS CITY, Kansas (Reuters) – In a debate every parent of a six-year-old can relate to, the Kansas legislature is deciding who can pull baby teeth.

The problem is that rural areas in the United States have a shortage of dentists, and one proposed solution is to license “dental practitioners” who could do things such as fill cavities and pull baby teeth.

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  Human Body
  
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But the lobbying group representing dentists in Kansas wants no part of non-dentists messing with people’s mouths, saying that only a person with a four-year graduate degree and additional training should be allowed to extract teeth.

“When a dentist cuts into a tooth, that’s surgery, even though the public may not think of it that way,” said Kansas Dental Association Executive Director Kevin Robertson. Tooth extractions, even of loose primary teeth in children, can get complicated, he said.

About half the 105 counties in Kansas have two or fewer dentists and there are 15 counties with no dentist at all, according to a state report.

Rural counties across the United States struggle to attract dentists as dental school graduates tend to favor the higher pay and amenities of larger communities.

The United States has been slow to adopt dental practitioners, with only Minnesota and Alaska allowing them, although 15 states are considering the idea. A recent study by the W. K. Kellogg Foundation, a Michigan-based child healthcare advocacy group, found that dental practitioners permitted in 54 countries provide safe and effective dental care to children.

In Kansas, the debate has landed in the state legislature.

One group that advocates child healthcare is pushing legislation to allow practitioners to fill teeth and remove baby teeth, along with teeth cleaning that dental hygienists already provide. The bill would require practitioners to spend their first 500 hours of practice under supervision of a dentist. Once on their own, they would still have to refer non-routine care to dentists.

“We are seeing a lot of people going without care or having to wait a tremendous amount of time to get basic dental care,” said Suzanne Wikle, director of policy and research for the Kansas Action for Children. “Others have to travel great distances to get that care.”

But Robertson said practitioners could further reduce the number of dentists in rural areas. Dentists would be less likely to move to an area where they see that dental practitioners are already in business, he said.

The dental association is pushing legislation in Kansas that would expand the services of hygienists to include temporary fillings and adjusting dentures. On the subject of baby teeth, the dentist lobby would allow extractions only if the teeth are very loose. The bill has passed the state House and is awaiting approval in the Senate.

The dental association proposal falls far short of meeting the needs of patients but is “a very small step in the right direction,” said Wikle. Her group has vowed to return next year to again seek a broader bill that permits dental practitioners.

(Editing by Greg McCune and Eric Walsh)

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