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Interface - Comunicação, Saúde, Educação

Print version ISSN 1414-3283

Interface (Botucatu) vol.3 no.se Botucatu  2007

 

Conflicts in the practice of Dentistry: the autonomy in question

 

Dilemas no exercício profissional da Odontologia: a autonomia em questão

 

Conflictos en la práctica odontológica: la autonomía en cuestión

 

 

Cláudia Helena Soares de Morais Freitas1

Post graduation program in Dentistry Federal University of Paraiba, Joao Pessoa - PB- Brazil. chmfreitas@yahoo.com.br; chsmfreitas@hotmail.com

Translated by Eraldo José de Aguiar Júnior
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.11, n.21, p. 25-38, Jan./Apr. 2007.

 

 


ABSTRACT

The study aimed to arrive at an understanding of the dynamics and the changes faced by dentistry, using the professional autonomy category and its significance to professional discourse and the strategies that are used to preserve professional autonomy. The reflections are based on the sociology of professions, particularly the concepts of autonomy, expertise and service ideal. The research revealed that professional autonomy is still a strong element with an important role to play in shaping the identity of the group and that autonomy has not been affected in spite of changes in the labor market.

Key words: Dentistry. Sociology. professional practice. professional autonomy. labor market.


RESUMO

O estudo buscou compreender a dinâmica e as mudanças que atingem a profissão de dentista, com base na categoria autonomia profissional e seus significados no discurso da profissão, e que estratégias são utilizadas para preservar a autonomia profissional. As reflexões são fundamentadas na sociologia das profissões, particularmente nos conceitos de autonomia, expertise e ideal de serviço. A pesquisa revelou que a autonomia profissional continua a ser um forte elemento que conforma a identidade do grupo, não estando abalada, apesar das mudanças do mercado de trabalho.

Palavras-chave: Odontologia. Sociologia. prática profissional. autonomia profissional. mercado de trabalho.


RESUMEN

El estudio buscó comprender la dinámica y los cambios que afectan la profesión del odontólogo, a partir de la categoría de la autonomía profesional y sus significados para el discurso profesional y las estrategias que se utilizan para mantener la autonomía profesional. Los pensamientos son fundamentados en la sociología de las profesiones, sus conceptos de la autonomía, expertise e ideal de servicio. La investigación reveló que la autonomía profesional sigue siendo un fuerte elemento para la identidad del grupo, no se ha alterado a pesar de los cambios observados en el mercado de trabajo.

Palabras clave: Odontología. Sociología. práctica profesional. autonomía profesional. mercado de trabajo.


 

 

INTRODUCTION

The definition of a profession has historically undergone the possession of a certain degree of autonomy legitimised and organised by control of its own work which means the exclusive right to determine who and how a person can exercise such profession. Some professions and among them Medical Doctors and Dentists were able to be the judges of their own performances under the justification that they are the only ones capable of evaluating their performances adequately furthermore guaranteeing basic standards. As a profession, they have the expertise and the ideology of an independent and quality service to society.

The insertion of Dentistry in the public service was constituted as health care for children on school age and to a great majority of the poor population, the most common practice was tooth pulling. Machado (1995) considers that if on the one hand, technological innovation produced solid knowledge which enhanced the competence and the action fields, on the other, it did not improve the enhancement in the quality of the services provided by dentists and in general, treatment of teeth problems has been restricted to the most privileged strata of our society. The success and consolidation of Dentistry as a profession refer to its liberal practice, thus, making questionable its benefits to society as a whole.

Medical profession studies on market questions (Donnangelo; 1975 Machado et al., 1992) and of professional autonomy (Machado, 1997, 1996, 1995; Schraiber, 1993) in spite of different approaches, they point out that medical practice has undergone a transformation process from a liberal, individual practice which valued clinical experience to an institutionalised practice with a strong tendency to rationalization showing multiple forms of insertion and pinpointing the acting of group medicine.

As to the dentists practice, Machado et al, (1992) point out that among dentists, the autonomous group is rather large. The decrease in the number of autonomous professionals in the 70s of the 20th century was small. From a percentage of 69, 9% in 1970 to 54, 5% in 1980 of the total number of dentists.  The research of Silva Filho and Eleutério (1977) made in Araraquara (SP) with surgeons that graduated from 1964 to 1974 showed that 61, 1% of these only worked as private surgeons.

Dentists work market suffers a lot of modification in the 1980s. Many studies show the tendency to wage receiving, a tendency of surgery practice combined with deed covenant and credentials and the association of both forms. The research of Pereira & Botelho (1997) made with 3,191 dentists in the State of Goiás shows that 51% were liberal workers, 48% worked as deed of covenant, 49% are common workers and receive salaries and 45% work in their private surgeries and receive salaries.

Jardim (1999) in a survey made in João Pessoa/PB noticed that 78, 4% of the dentists work in surgeries, 59% are civil servants and 9, 9% have a private job. Of the considered autonomous, 61, 6% work with deed covenants and the great majority (54%) for less than five years.

The survey carried out by the Regional Council of Dentistry of Minas Gerais State in 2000 with 1,199 surgeons of the state identified that 65,9% of the professionals are liberal workers exercising dentistry in surgeries, 56,2% of them work with deeds of covenant and credentials; those who are liberal workers and receive salaries are 25,2% and 8,7% are paid workers.

In a survey carried out by dentistry entities in 2002, 614 dentists were interviewed in Brazil. As to professional share, 26, 6% are civil servants, 11, 1% are private sector workers, and 89, 6% work on their own surgeries as liberal professionals. A percentage of these (56, 2%) work with deed covenants and credentials. Of the civil servants, 48, 5% are in the Family Health Programme or PSF (Ministry of Health, 2003).

Reflections about professional autonomy are based on the sociology of professions having as a basis concepts such as autonomy, expertise (Freidson, 1970; 1994) as well as the concept of ideal of service developed by Moore (1970).

Most authors in the field of sociology of professions consider that the main characteristic of the occupations considered professions is the esoteric knowledge acquired through a prolonged formation (Goode, 1969; Moore, 1970; Wilensky, 1970; Friedson 1970, 1994). By that, the monopoly of knowledge is defended, the control over work and, thus, the capacity of regulating itself as an activity and have independence in its development and practice.

The ideal of service or the collective orientation encompasses rules that have as aim to guide technical procedures which focus on the clients rather than professionals and are considered one of the key elements in the process of professionalization (Goode, 1969; Moore, 1970; Freidson, 1970). The professional's behaviour has to be based on the ethical code in relation to clients and other professionals.

The central object of this study is to comprehend the vision of the professional in relation to its working context, the pitfalls that professionals face in different spaces and types of practice as well as the strategies developed to overcome and preserve their work autonomy. The main foci are the technical and market autonomies as axis of the professionalization process taking into account reflections of professionals about their practice.

 

METHODOLOGY

This is a field survey of as qualitative approach. To obtain the data, it was necessary to combine life story with semi-structured interview (Becker, 1999). As Minayo (1994) points out, the qualitative survey has as its main characteristics: openness, flexibility and capacity of observation and the interaction with the social actors involved.

Semi-structured interviews were carried out with 12 dentists of João Pessoa County in the State of Paraiba, Brazil. Three of them are experts of dentistry health plans. Following the qualitative tradition to come to this number, the criteria of exhaustion and saturation were followed, that is, when the researcher verifies the formation of a whole and recognizes recurrences in the collected data (Blanchet & Gotman, 1992).

The research was approved by the ethics committee of Federal University of Paraiba (UFPB). To carry out the interviews, it was previous explained to interviewees the objective of the study and each signed a consent term observing the ethical and scientific demands of surveys with human beings as stated in the Resolution 196/96 of the National Health Council (Brazil, 1997).

The interviewees were randomly selected based on the list of specialists provided by the Regional Council of Dentistry – Paraiba Section and obeyed the following criteria: 1) professionals who were working in the period of the study; 2) professionals of different specializations; 3) professionals with different market insertions and different experience of work (more or less time) to characterize the undergoing of market transformation so as to reflect a degree of heterogeneity which exists in reality; 4) the interest of the professional in taking part in the study.

Interviews were carried out following a preliminary script evaluated through a pilot interview. The interview dealt with themes such as the choice of profession, daily practice, problems faced by professionals in daily practice that result from the job market transformation and what strategies professionals use to preserve their autonomy.

Based on the literature about sociology of professions, more specifically on the contributions of Freidson (1970, 1994), Goode (1969), Larson (1977), Moore (1970), Schraiber (1993) and Ribeiro & Schraiber (1994), we elected the following criteria for analysis which are inter related.

- Autonomy as a professional identity element: technical autonomy is related to the capacity of judgment and decision making in the work process and constitutes a theoretical category which makes it possible to articulate knowledge and power; market autonomy has to do with the capacity of the profession to sell itself in the service market.

- Expertise – knowledge as a fundamental element to characterise a profession.

- The ideal of service considering the social commitment of the professional so as to contribute to the improvement of health conditions of his or her patients.

 

RESULTS AND DISCUSSION

The interviewed professionals were eight female and four male, all graduated between 1979 and 1996 and ages varying from 29 to 45 years old. Nine of them are specialists; three are general practitioners and have made post graduate courses at updating and improvement levels. The three general practitioners work as experts in dental care enterprises.

The reasons that influenced in the choice of profession are related to individual and social questions. One common aspect to all is the choice of health area. Other aspects are important in the reports such as the interest for a profession that has liberal characteristics and the possibility of having a good income and be independent. This was the image that they had of the profession: a liberal profession, although the reports showed a discrepancy between what was real and the imaginary when it came to work market position. There were reports of professionals who arouse the interest and vocation to the profession.

It was possible to notice the various forms of insertion of dentists in the work market: five of them are paid workers and work in their surgeries under the "liberal" flag working with deed covenant and credentials; two are paid workers and work in their surgeries under the "pure" liberal form without deed covenants or credentials; four of them work only in their surgeries accepting deed covenant and credentials and only one of them is purely a wage worker, working as a teacher.

The first years after graduation are for an effective insertion in the work market followed by a search for a specialization. The main interest is to improve clinic experience once trainee jobs are not enough to give professionals the required experience they need in practice. A common trait among all interviewed is that they started their professional lives under a dentistry that no longer liberal, that is, they put together experience in private surgeries in the outskirts of cities as underemployed with no working rights, as private or public paid workers and the work in surgeries under the liberal flag either individually or sharing a surgery with colleagues.

 

LIBERAL PRACTICE: THE FEELING OF CHANGE

Almost all interviewed referred to the association between professional autonomy and the concept of a liberal profession. In a study by Machado (1996), doctors also associate autonomy to the liberal profession concept. The concept of liberal practice means the way in which the professional markets his or her services in the market determining how he is paid for that and the bonds of clients—how the patients freely choose them.

It was possible to identify many forms of insertion of dentists in the market as paid work and work in surgeries with health plans as pointed out in studies about medical profession  made by Donnangelo (1975), Machado (1996, 1997), Schraiber (1993).

When I graduated (1986), the idea of a liberal professional was still around. This was the philosophy of professors at University, of graduating and working in a private surgery. We had the idea of finishing the course and to be free to work in a surgery but reality is not like that. To be a liberal professional was the objective in life but when you start working you really see this aim even more distant. I never had the chance of being a pure liberal professional mainly to depend exclusively of my surgery. I worked in the surgery but I was also a paid worker. (Teacher)

I did not know the liberal dentistry. I started my professional life in the late 1980s as a civil