by Joanne Iannone Sheehan, RDH, in collaboration with Carol Bartoschek, RDH
Beate Gatermann, a dentist's daughter, was born in the city of Ulm, Germany, and given a name that means "happy" in Latin. Her father was one of the best dentists in Germany and kept up with the latest developments in dentistry. To her father's delight, Beate (pronounced Be-ah-t) became interested in dental hygiene. When she was 19, she enrolled in a two-year German school for dental assisting to get her background in dentistry. She wanted to study hygiene in Switzerland, but its program was still a few years away from being established. The renowned Professor Muhlemann, who co-founded the hygiene program in Switzerland, suggested to Beate's father that she study in America.
At age 21, Beate applied to William Rainey Harper College in Palatine, Ill. She was one of 45 applicants accepted from a pool of 250. She received her dental hygiene degree in 1974. Foreigners were not allowed to take the state boards in Illinois, so she took the Minnesota boards instead. Even then, she was wrestling the "red tape monster" and vowed to let nothing destroy her professional dreams.
When Beate returned to Germany with her American license, she was the first certified hygienist in her country. She worked with her father and looked for ways to improve the dental profession in Germany. For example, she founded the DDHV (German Dental Hygiene Association) in 1991. The legalities were overwhelming, so Beate employed the services of Thomas Reisinger, a lawyer who specializes in public matters in Munich. Beate not only had to convince other hygienists to become members of the group, but also persuade the court which deals with the founding of associations. All prospective members were required to prove they possessed internationally recognized training and credentials. Only after Switzerland founded its first association did the German court follow suit and allow the DDHV to exist. The association's goal was - and still is - to set a high standard of internationally recognized education for hygienists.
Beate didn't stop there. She saw the bad working conditions in the German dental offices. Back then (as is still true today), dentists didn't scale teeth; they had their uncertified assistants do it with little or no training, while charging patients the same as if they had seen a qualified hygienist. There were between 150 and 200 foreign-trained hygienists in Germany, most of whom were grossly underpaid. Many hygienists, especially Americans, worked only a short time in these offices and then left, making sure none of their colleagues made the same mistake of working there. Beate set out to declare freedom for hygienists and strive for independent practice. She studied and received her second diploma from Switzerland, arming herself with more professional credentials which would later aid her in her fight for independence.
Working with Reisinger, Beate researched the status of dental hygiene in other countries. She even secured a 200-page report from the American pilot study of six independently practicing hygienists in Colorado in 1983. In total, she collected roughly 400 pages of data which she had translated, using money earmarked for two family vacations. She put together an international report on hygienists in independent practice, and submitted it along with her other international findings to the Bundestag (House of Parliament) in Bonn in 1997.
The petition was accepted by the Committee of Petitions on Dec. 3, 1998, and passed the House of Parliament the next day. Still, the health department (a branch of the Parliament) postponed the new law and the legalization of dental hygiene as a paramedical profession. But, during this postponement in Germany, two politically important statements came forward expressing that dental law can work with dental hygiene as a separate profession.
Seven years ago, the IFDH (International Federation of Dental Hygienists) accepted the DDHV as a member. With the backing of the IFDH, educational standards have been closely scrutinized. Neither the IFDH nor the DDHV have accepted any form of training in Germany because of the low standards. None of the training centers had the necessary state board examination or the means to train hygienists well enough to qualify them for independent practice.
In 1991, the German health department was ready to grant independence to qualified hygienists, but the plan was vetoed. A group of dentists who wanted dental hygiene to be considered as an auxiliary profession opposed the grant.
"There are three schools that are now involved in continuing education for dental assistants to become hygienists," Beate said. "I am attempting to involve professionals (from an accredited dental hygiene school in Switzerland) in evaluating these programs because none of them are internationally accepted, meaning they don't include injections and independent practice. Other European countries reached this goal ages ago. The Dental Chambers (Dental Association) is currently training them in a pilot program, but the clinical education is minimal and not as good as the United States'. That is one reason they have been denied independent practice.
"We want to force the German dental profession to raise the level of this education. In about five years, we will also have dental hygiene training via the university. The students will have to be high school graduates to enter the three-year course - which will include injections and certifications - to practice independently."
At the Symposium for the International Federation for Dental Hygienists in Florence in 1998, Beate gave the first report concerning independence for hygienists. She is determined to help her country achieve not only freedom for hygienists, but also the high standard of education needed to handle this responsibility. Beate has attained independent practice for herself with the help of a degree received in the United States, a diploma in Switzerland, and her lawyer, who has been a tremendous asset in this fight for 10 years. She is the first hygienist in Germany to practice autonomously.
"I can do everything an accredited hygienist worldwide does, but I am especially alert in regard to pathology. You have to be when you're standing on your own two feet," said Beate, whose procedures are limited to debridement and scaling to about 6 mm in depth. "I am not doing perio work or injections by choice. I stick to the rules they have in Switzerland. When you're the first one to do something and everyone is watching, you don't want to make any mistakes. Taking radiographs would be more than great because about 78 percent of the radiographs I receive are nondiagnosable. The future is in better X-rays with less exposure time."
Right now, Sweden is the only country where hygienists in their own practices are allowed to take radiographs with a doctor's order.
How are patients accepting independent practice?
"My patients love it and think it is the greatest move ever! I do offer (via Computerprints and the Internet) a very close connection with the dentist," she said.
You can see what she means by "Computerprints" by going to her Web site at www.dentalhygienepraxis.de, and clicking on Aufgabenberich in the left column and then Befunde (findings). Beate has compiled an enormous amount of information on this site about the fight for hygiene independence in scores of countries. She has links to the IFDH, the DDHV, and even the ADHA.
When asked how American dentists compare with their German counterparts, Beate said, "There are just as many good ones here as there, but dental hygiene is something totally different. All the beautiful American teeth with all the junk food being sold and eaten! It works only because caries prevention starts right after birth. Also, I really miss the American fluoride treatments - once every six months, really strong. Unfortunately, we do not have this. Our pastes are good, but not as good as the American gels." (In Germany, Switzerland, and Austria, a concentrated fluoride paste is used once a week on patients aged 6-18.)
With these changes, Beate has had to endure constant opposition from dentists and even their wives. They have basically set up a boycott, intolerant of any change in the status quo, while the countries around them are changing and progressing. Dentists who are brave enough to refer to Beate are often criticized by colleagues. Even some hygienists voice opposition. Nonetheless, Beate is determined to see it through, and she has made some American friends in the trenches.
Carol Bartoschek, RDH, is an American working in Germany.
"As the president of the newly formed European Association of Registered Dental Hygienists (EARDH), I was interested in forming a partnership with the DDHV," Bartoschek said. "I was given Beate's name as a contact person for this group. The two of us 'clicked' from our first telephone conversation. A table clinic, with information on the EARDH, was presented at the 9th and 10th Annual DDHV Meeting and Conference, with Beate's help as the organizer of these events. After meeting in person, we realized we had much in common, from our profession to the ages of our children! This has turned out to be a viable friendship, with each of us aiding the other in the fight to enhance the dental-hygiene profession in Europe."
And what a fight it has been.
"I am not going to give up, no matter what happens," Beate said. "Only when my office succeeds, after 30 years of discussing this profession in Germany, will we finally get an internationally accepted education, everything included."
Because she is a widow and mother of two teenage boys, working in her home is very important to Beate. She is a trail-blazer and doesn't mind a good fight. "Remember, after the first one goes through things, the next ones don't have to bother," she said. She is watching how American hygienists are handling their fight for freedom.
"The United States - for a change - is sleeping," Beate said. "Once again, dental hygiene is not included in any dental laws worldwide. Hygienists do not do 'dentistry.' We practice 'dental therapeutics' - the process of achieving and maintaining a patient's oral health. Once American hygienists finally get this, they can take the states that do not have independent dental hygiene and put together a petition for the lawmakers in Washington. Dental therapeutics. Das ist das Schlagwort dafur. That's the word for it used in many reports, even in the United States. Find a lawyer like mine who does not want to charge you, but sees social gratitude as his goal and success as his reward. After all, united we stand!"
After interviewing Beate, I wondered, "Is it semantics and wording that is holding us back?"
"Anytime there is another legally sanctioned independent practice of dental hygiene, it is time to celebrate," said Gail Gilman, RDHAP, BSDH, MS, volunteer lobbyist for "the cause" and contact person for the 1998 Symposium on Dental Health Practices. "Beate Gatermann's long-standing determination and success in gaining 'independence' in Germany is a great achievement. We here in the United States will look upon her future success with watchful and sleepless eyes. I wish her the best, and I hope more countries will follow her lead.
"She may think of hygienists in the United States as a sleeping giant, but I see us more as a traumatized giant. There is something wrong when, after a prolonged history to win independence, we have only one state (Colorado) that succeeded in achieving the only true independent practice."
Isn't autonomous practice the natural progression of a healthy and evolving profession like dental hygiene? Beate Gatermann, RDHAP, seems to think so. Heading her report titled "Independent Work as a Dental Hygienist: A Worldwide Resume," she uses a quote by Victor Hugo that sums it up...
"Nothing is stronger in this world than an idea whose time has come."
Joanne Iannone Sheehan, RDH, is a frequent contributor to RDH. She is based in Huntsville, Ala.
"I can do everything an accredited hygienist worldwide does, but I am especially alert in regard to pathology. You have to be when you're standing on your own two feet." - Beate Gatermann
What's in a name?
Here at home, the idea of autonomous practice raises a lot of questions. What exactly is meant by "autonomous" or "independent" practice? The levels of supervision needed for different functions in individual states prove so diverse that a two-page overview chart from the ADHA is necessary to fully understand.*
There are several terms describing innovative and less restrictive forms of practice which are close to unsupervised - "limited access permit RDH" in Oregon, "registered dental hygienist in alternative practice" in California, and "collaborative" in New Mexico. In New Mexico, the RDH must have a contract spelling out how he or she will collaborate with the dentist, which then must be reported to the Board of Dental Health Care. After this, he or she can treat patients based on a protocol established individually with the dentist, but not requiring authorization for specific treatment of patients. Collaborative practice is unique to New Mexico as far as dental hygiene is concerned.
- General supervision means the physical presence of the dentist is not required.
- Direct supervision means the physical presence of the dentist is required.
Thirty-four states (plus the District of Columbia) are under general supervision, while the other 16 states are under direct supervision in the dental office. Eight states allow practice without a dentist's presence or authorization required outside the dentist's office - such as long-term facilities, hospitals, and/or independent hygiene practice - but these may require for a type of cooperative arrangement with the dentist. Nine of the states requiring direct supervision in the private dental office require no dentist's presence or cooperative arrangement off-site. The functions in question here consist of scaling and prophylaxis.
Right now, Colorado is the only state where there is a specific section in the law authorizing hygienists to own a private practice equivalent to a private dental office. Authorization for exposing radiographs is still necessary.
You can obtain this overview chart from the ADHA by contacting them online at www.adha.org or calling (312) 440-8925. Ask for the ADHA Practice Act Overview Chart of Permitted Functions and Supervision Levels by State.
The idea of autonomy is spreading
As of October 2000, the European countries that have achieved autonomous practice are The Netherlands, Norway, Sweden, Finland, Denmark, Switzerland, and Italy. Spain has applied while Portugal has not yet applied, but its hygiene education meets international standards. Israel's Dental Hygiene Association is striving for autonomous practice. Both British Columbia and England have independent practice for hygienists, with England now having a four-year university program.
You can get more information about these countries on Beate's Web site at www.dentalhygienepraxis.de and clicking on the flag next to Tabellarische Ubersicht (overview) at the top of the second screen.
Want to keep reading?
For more information about independent practice, you can read past RDH articles by logging onto www.RDH.net. For example, if you "search" for "Rocky Mountains," you can read two articles written by Cathy Seckman and Wendy St. Cyr that appeared in the August 2000 issue.