What the Tooth Fairy Forgot: Dentists for Rural America
By: JODI WILGOREN
NY Times, August 7, 2002
GREGORY, S.D. — Dr. Donald E. Nemer does not like
to make people in pain wait.
So when the patient of a vacationing dentist called
with a toothache one recent afternoon, Dr. Nemer squeezed him into a full
schedule already made fuller by a walk-in denture readjustment, an
emergency filling and an unscheduled root canal.
Yet Dr. Nemer himself has been waiting for four years
to retire, as a shortage of dentists in rural stretches of the upper
Midwest reaches crisis proportions.
"You shouldn't have to work until you drop dead
in your shoes," said Dr. Nemer, 70, who had heart surgery in 1998 and
has recently cut back on daily golf games because of a bad back.
Dr. Nemer had planned to retire five years ago but
has stayed on because he cannot find anyone to take over the thriving
practice he built over a lifetime in this isolated farm town of 1,342
people about 180 miles southwest of Sioux Falls.
In the years since he hung his shingle around the
corner from where he grew up, Dr. Nemer has instead watched colleagues
around the county close up shop.
There is one dentist for every 2,359 residents of
South Dakota, compared with one for every 1,714 people nationally — and
one for every 1,254 in New York State. Dr. Nemer does not keep an exact
count but says he has 4,000 to 5,000 active patients, and more than 2,439
have come to see him since the beginning of the year.
Though there are more dentists than ever across the
country — 166,383 in 2000, up from 150,762 in 1991 — and more people
than ever seeking dental care, there are critical shortages of dentists in
the Plains as well as in sparsely populated sections of northern New
England and the fast-growing suburbs of the Southwest.
In the Dakotas, the situation will soon get worse.
Thirty percent of South Dakota's dentists are 55 or older, and an
additional 40 percent are 45 to 55. The state has 320 dentists today, down
from 361 in 1999. A survey of North Dakota's dentists showed that 40
percent planned to retire in the next decade.
The shortage has multiple causes, with discouragingly
familiar results in places like Gregory, which have long struggled to lure
young professionals and entrepreneurs to their sleepy main streets. Many
dentists, like other professionals, shun small towns, where fees for their
services are usually lower than in cities. Young dentists with student
loans of up to $100,000 to repay say it can be a hardship to practice in
rural areas, where many patients are poor, because Medicaid reimbursements
often barely cover overhead.
In the single-stoplight towns that separate the vast
cornfields, the dentist is becoming a vanishing breed, like the lone
gunslinger and the traveling salesman.
In Milbank, S.D., on the state's eastern edge, Dr.
Mark Bierschbach has had to let six-month checkups slip to seven months
and often cuts his lunch hour to 15 minutes. In Scotland, S.D., to the
south, Dr. Curtis Johnson is booked for up to 10 weeks. Dr. Howard Reinke
could not sell or give away his practice in Hankinson, N.D., in the
state's southeastern corner, so he just keeps thousands of files in his
garage.
"They're taking up a lot of space, too,"
Dr. Reinke said, adding, of the next generation of dentists, "You
can't get them out to the little towns."
Dr. David O. Born, professor and director of the
division of health ecology at the University of Minnesota Dental School,
warned, "Over all, oral health is going to deteriorate."
"More kids are going to be going to school with
teeth that hurt," Dr. Born said. "More and more workdays are
going to be lost, and more adults suffering from dental pain will face
longer waits at the dental office."
To combat the problem, the Dakotas have formed
partnerships with dental schools like Dr. Born's to attract students to
rural patches of their states for clinical internships, helping alleviate
the crunch while introducing dentists-to-be to the charms of a small-town
practice.
South Dakota and other states are considering
legislation like that adopted in North Dakota last year to repay dentists'
student loans if they agree to practice in needy small towns for four
years. But North Dakota found only one taker for its three spots last
year.
Here in Gregory, crowned the capital of pheasantdom
by Fortune magazine for its prime hunting, Dr. Nemer keeps careful track
of South Dakotans enrolled in dental school. He sends them personal
letters bragging about his hometown's amenities, including a movie theater
(open Friday to Monday), a 58-bed nursing home, three golf courses and
"the best walleye fishing in the world."
Three young dentists have visited. No takers. So Dr.
Nemer keeps coming in at 8:30 each morning, zipping on his red clinic
shirt and quietly caring for the endless rotation of patients in his
chair.
Rachel Lovejoy, 4, traveled 68 miles from Mission,
S.D., with her mother one morning for her first visit to the dentist, for
treatment of five cavities eating away at two teeth. Her mother, Mary Beth
Assman, has been going to Dr. Nemer since she was a child. Her parents
were recently in to see Dr. Nemer.
"This is the best dentist in the country,"
Ms. Assman said, recalling how she telephoned Dr. Nemer at home one night
when her older daughter had a problem with a filling. He had told her to
apply Vaseline but to call back, and take the girl into the office, no
matter the time, if it did not improve. "You come, it gets fixed that
day," Ms. Assman said,
Unlike big-city dentists who send patients to oral
surgeons and periodontists, Dr. Nemer is a one-man show, save for a
part-time hygienist and an orthodontist who stops by monthly.
One recent day, Dr. Nemer arrived at the squat beige
office behind the community health clinic to find 11 appointments on the
calendar. Four more patients arrived in the course of the day. When the
last one left, at 4:30 p.m., Dr. Nemer's grandchildren, 6-year-old
triplets and their 10-year-old brother, visiting from Omaha, took their
turns getting a cleaning.
"It makes an old man out of me," sighed Dr.
Nemer, who vows to retire at 75, no matter what. "There's other
things in life to do, you know.
"I love my profession, that's the reason I'm
still in it. I don't want to leave this area and my patients without a
dentist just because I want to quit, so I'm trying to hang on."
Dr. Nemer is as gentle holding 4-year-old Rachel's
hand before her first dental X-ray as he is with a 91-year-old Alzheimer's
patient who is sure her cousin walked off with her dentures (in fact Dr.
Nemer took them to add several new teeth). He first contemplated his
future vocation at age 5, walking past the dentist's office on the way to
his father's shoe store (Eli Nemer, a Lebanese immigrant, retired in 1979
at age 85, unable to sell his business, either.)
It is not just that Dr. Nemer, a former City Council
member who helped raise $465,000 for Gregory's new library and built three
low-income apartment buildings in town, knows everybody here by name; he
knows how many fillings they have. The chiropractor; the waitress at the
corner cafe; the editor of The Gregory Advocate; Dr. Nemer's wife,
Lorraine; his brother, Gene, a local physician — they are all patients.
Ken Giedd's chart at Dr. Nemer's office starts in
1960, when he was 7. But it ends in 1970, when Mr. Giedd started seeing a
dentist in Winner, 26 miles west, until he turned up the other day with a
toothache.
Dr. Nemer wrote out prescriptions for penicillin and
Vicodin, then gave Mr. Giedd his X-ray to take to his regular dentist.
"Why don't I just leave it here?" asked Mr.
Giedd, who works at the Cen-Ex gas station in town. "It'll work out
better for me to come here."
"Well," Dr. Nemer said, pushing the X-ray
into his patient's hand, "I'm trying to slow down a little."
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