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Washington State Dental Association

2014 Citizens of the Year: Drs. Amy Winston and Bart Johnson

 Each year, WSDA members from across the state nominate one of their own to receive the Association’s highest honor, the Citizen of the Year Award. Steeped in tradition, the award honors the dentist who has displayed exemplary service to the community through civic/charitable activities, whether dental-related or not. 

This year, rather than choosing just one recipient, the Committee on Recognition chose two: Drs. Bart Johnson and Amy Winston, the workhorse partnership behind four charitable programs in Seattle (five, if you count the staggering amount of uncompensated care they provide at their private practice) designed to create access for some of the state’s most vulnerable populations — medically-complex and challenging patients, the poor and the uninsured, and patients with cancer and renal failure.

To say that they have had an impact on access in the community does not adequately characterize the scope of their practice or charitable work. Last year, their private practice — Seattle Special Care Dentistry — provided $231,000 of charitable care, not including hundreds of thousands of dollars written off to Medicaid for treating other low-income patients. All of the colleagues we spoke to about Johnson and Winston lauded the pair as visionary, collaborative, and endlessly energetic in their passion to help the underserved. As Dr. Sarah Vander Beek, dental director at Neighborcare says, “They have a style that is both flexible and innovative. Their passion seems bottomless – they don’t lose their focus or energy. They’re busy, but they make the time for CHCs and mentorships, which is awesome.”

Winston and Johnson were nominated to be Citizens of the Year because of their work in four projects, each of which had its starting point in their private practice: Northwest Kidney Center Screenings, the Swedish Community Specialty Clinic, the Golden Ticket Emergency Department Diversion program, and the Head and Neck Reconstructive Team, their newest collaboration. 

Dr. Noah Letwin, a former resident in their GPR and now Dental Director for the Swedish Community Specialty Clinic, says, “One of the things that I enjoy about the types of projects Bart and Amy work on is that they are big picture projects — they’re not helping one or two people, and it’s not a mission trip to a faraway place. Those are also lovely projects, but they don’t have the legs of the work Amy and Bart are doing here. Both of them are concerned with putting systems in place and creating local projects that are long-lasting and will help people for years to come.” The work is tough, but never boring. Johnson says, “You learn a lot about medicine working with this population — I love it because it’s professionally satisfying from an academic and personal point of view. Many of these patients can be challenging — medically, personally, even physically.”

But one has to wonder — are these patients ever too much for the pair? Winston says, “There are times that we have patients who are so psychiatrically impaired that they come off as incredibly offensive and problematic, and sometimes we want to run the other way. But then the discussion we usually have is, ‘Okay, if we don’t treat this person, who will? Where will this person go?’ We know we are the end of the road for so many of these people. And that’s how we see ourselves – we try to be the dental backstop for the most difficult patients.”

Getting started in private practice 
They met in 2002 when Winston was a resident at the UW General Practice Residency. Johnson was the program’s director, and one of a core group of early influencers for Winston, who says, “During those early, formative years in my career, Bart was the one who showed me a lot of things. He’s the one you want around when you have a really challenging situation and you’re not sure exactly what to do – he can usually figure it out. That works really well in a residency program because novice dentists are unsure of themselves, and having someone like Bart around makes everything so much more comfortable. That is the gift he brings to the profession” At the UWSoD, the pair was working with the same medically-complex populations they both find so fascinating, but in 2007, when changes in the political climate at the UW materialized, they began to look at options outside of academia. Winston suggested they privatize. For Johnson, it was an “aha” moment — something he’d never considered — and perhaps a harbinger of things to come. Winston was honing her knack for putting together ideas, programs and people, something she truly excels at today. 

Their strength lies in their differences — as Letwin says, “They complement each other beautifully. They’re not afraid to get their hands dirty when they’re working through a problem or question. Ultimately, the give and take results in a better solution than had one of them just rolled over without challenging an aspect of a program. The process can seem loud and argumentative at times, but these are people with thick skins and sharp teeth. They’re willing to go at it, circle around a problem until they come up with a solution they both like. That’s what makes them such a remarkable team – at the end of the day, they both want to be satisfied that the product they’re putting out is going to be the best product it can be. They are both very deserving of the award and would be even individually — but because they have done so much together it makes perfect sense to award them together.” 

Johnson, he says, “Is hands down the finest educator I have ever met. He can sit down with a group of people and explain the technical skills necessary to make a project successful — whether it’s lecturing to volunteers so that they can safely treat renal patients, or giving our residents the didactic lectures they need to go and treat medically-complex patients in our extraction clinic or elsewhere. Bart’s not only very detailed when he lectures, but the breadth of what he is able to teach effectively is staggering” Winston concurs, “Bart is highly sought after on the lecture circuit, and spends a lot of weekends flying to major dental conferences all over the country delivering lectures. His impact on the profession is profound — the number of people who learn from him, the number of residents who learn from him – it’s one of the biggest gifts that he has to offer. He certainly taught me…although he doesn’t teach me much anymore,” she says with a genuine laugh, clearly enjoying ribbing her partner. 

By all accounts, Winston’s biggest strength is that she is a team builder – she’s able to identify the components of the project and determine the right players to bring together for the team. She’s a tenacious organizer, and her follow through is the stuff of legends. Says Letwin, “She puts a tremendous amount of time and energy into making a project happen, organizing multiple stakeholders like SKCDS, WDS Foundation, Swedish, and Burkhart, getting them talking, and moving the project forward.” Johnson says, “She is fearless – not afraid to come up with a new idea that no one’s ever thought of. She is a wonderful team builder. I enjoy sitting back and watching her at meetings because she can really make people understand the vision of a project and get them excited and on board. Once she formulates her team, she’s really good at figuring out how to make it so a project can’t fail – she finds the right people, the right resources, she brings everything in, and at the end of the day you can bet money that the project will work. And if it starts to falter, she’s on top of it – she’ll change things up and make it right. She does stuff that I simply am not good at and vice versa, and we’re both very stubborn. We disagree now and then, but our disagreements are almost always beneficial to the project because we figure out a common ground.”

From academia to private practice
When they moved to private practice, their business vision included starting a new GPR residency. They knew they would need sponsorship from a hospital, so they drafted a business proposal and took their idea to Swedish — “We had no business experience,” recounts Winston, “And they could have just as easily told us they weren’t interested, but instead they were open to our ideas.” The two say that Swedish Administrators Sandy Norris and Dan Dixon were incredibly open to the possibilities inherent in the marriage of medicine and dentistry. They believed a dental team could work, and quickly committed to moving forward with the idea.

The transition period was a tough one for the pair — they shared call 24/7/365 for a year and felt a bit isolated from colleagues, at least until Dr. Chris Delecki approached them to join the Access Committee at SKCDS. “We joined, and felt incredibly welcomed and included,” says Winston. “Suddenly the dental society welcomed us into their community. We became really engaged — I got appointed to the Executive Council when one of the members couldn’t complete his term. I initially felt unsure of myself, but that changed when my ideas were supported and encouraged. It was a nurturing environment — there were leaders within the dental organization who really changed the game for us, and for that we will always be grateful to organized dentistry — and most importantly to Seattle-King. That’s why we continue to serve on committees even though our time is more limited. We’re committed to making sure our dental society knows we care.” Their vision of a clinic serving the most difficult patients in the county was becoming a reality, and would only serve as the fulcrum of many projects to come.

Today, their practice is balanced, with 60 percent of their base comprised of medically-complex patients of all kinds, the other 40 percent comprised of regular dental patients. The highly successful GPR they run in collaboration with Swedish pays it forward by bringing some of the best and brightest new graduates to the program every year, helping to train a new cadre of residents to treat the most difficult patients — 20 total residents since the program’s inception in 2009. “They’re bright-eyed, bushy-tailed, motivated to learn,” says Johnson. Winston agrees, saying, “We love our residents and the program we have here, they’re incredibly important to us, and so rewarding. It’s exciting and satisfying.” And while they know their grads will apply some skills and lose others depending on the type of practice they’re in, the intensity and range of exposure they get during the year allows them to incorporate what excites and interests them into their future practices. Johnson continues, “If our residents go out and have a regular dental practice but integrate a lot of what they learned in our residency, we consider that a success. At least we know they have the ability to do advanced work, so they have the option of not turning away patients with more difficult issues.”

From dialogue to inception — Swedish Community Specialty Clinic (SCSC)
It was during a conversation with Johnson and Winston at the opening of their practice with Tom Gibbon, manager of community programs at Swedish, that the idea of SCSC was born. As Gibbon explains, Swedish had already broken ground on a medical specialty clinic, developed because of a federally-required community health needs assessment that determined that access to care for the uninsured and charitable care were two of the top four needs in King county. Swedish worked with several CHCs and determined that primary doctors had no place to refer their uninsured patients seeking specialty care. Gibbon says, “That night, Bart and Amy suggested that we also add a dental component to the specialty clinic — because the CHC dentists also had no place to refer their specialty care patients.” The idea was so intriguing, and the community need so great, that Swedish stopped work on the project to allow time to modify plans and put in the infrastructure at the clinic for three dental chairs and support space. 

Even so, there was no funding to properly outfit the operatories – but the stakeholders joined forces to overcome the hurdle. Winston explains, “It became a wonderful collaborative effort between our practice, Swedish, SKCDS, the local CHCs, Project Access Northwest, WDSF, and several other granting organizations. Jennifer Freimund, the Executive Director of SKCDS, wrote several successful grants under the direction of the Access Committee. About $500,000 was raised for the start up and the first operational year. Vander Beek says, “The biggest impact they’ve had with us would be the SCSC, which has really changed our patients’ access to advanced oral surgery – it’s just life-changing for people. If we can’t meet their needs at our health center we have a direct and reliable pipeline that has predictable outcomes and is easy to work with. So as far as having a collaboration and partnership with them, it has been amazing. If you look at 2010 compared to now, it’s like night and day.” Winston says, “We’re so proud of the success of this clinic, but much of the credit goes to Noah Letwin.” “He is a huge part of why the clinic has been so successful – he is the one on the ground, making sure that things are running well, that the schedule works, that communication between the staff and volunteers is great. We put in the time and effort to get it started and still serve in an advisory role, but a great deal of the credit for the clinic’s success should go to Noah.”

The clinic has had a profound impact on the local community. It is open 4.5 days a week, currently receives around 300 referrals per month, and donated over $1.6M of care in 2013. This includes 4,744 extractions and 1,587 patient visits. In the first six months of 2014, the clinic has already donated $914,242 of care, 2,676 extractions and 888 patient visits. Additionally, the program provides emergency on-call services for the Swedish Emergency Department, allowing dental patients who present at the ED to be seen 24/7. Gibbon elaborates, “That’s what is so beautiful about this clinic – it’s all about collaboration between community partners. The program works well because it provides an alternative that wasn’t there before. People were being left untreated and wound up in the ED. It gave a referral source for the CHCs. It gives the right care at the right time. Instead of having a patient go through the ED five or six times for the same problem, they’re being referred to the SCSC and have the tooth or teeth removed, which eliminates infection. Any ED diversion saves money — it’s what Obamacare is all about. It also provides an alternative for the doctors who want to provide this care, but in a structured setting. Our dental program is a hybrid of volunteers, residents and preceptors who teach. It’s much more cost-effective care — because services are being provided by either a volunteer, a precept, or a resident.”

Vander Beek is working with Johnson and Winston on expanding their collaboration by adding an SCSC rotation for dentists in Neighborcare’s residency program “That will be a new bridge to our partnership. We realize the value of the experience there and want to have our residents get some of that advanced oral surgery training. We’ll put people into the pipeline with advanced skills, and we’ll help increase the capacity of the SCSC and allow them to be open five days a week, because the patient demand is so high. We’re evaluating our readiness and hope to collaborate in other ways as well.” 

As Letwin noted, this program has legs — it’s a model that should be easy to replicate elsewhere. In fact, Providence and Swedish presented the model to their strategic planners at a recent forum for potential programs in our state. The collaborative vision could help even more people in Washington and across the country.

Northwest Kidney Centers (NWKC)
Their work with NWKC started four years ago. Prior to it, Seattle-area patients often could not get listed for transplants because they lacked dental clearance, and so they simply stayed on dialysis. One patient had been waiting for a transplant for nine years because he had difficulty accessing appropriate dental care. “We started to do a lot of the clearances in our office, but it got overwhelming.” It was an unsustainable situation, so they worked with the SKCDS Access Committee and created a plan to partner with community volunteer stakeholders. The Northwest Kidney Center’s potential recipients are first screened by social workers and medical doctors to assess their eligibility for transplant, Project Access Northwest then handles all of the logistics of getting the patients to Seattle Special Care Dentistry for dental screening. “Project Access Northwest is really critical to the process because they take care of transportation, arranging for interpreters, and handle the management of patient logistics, which means there are not a bunch of no shows. It’s a great system,” says Johnson. 

The doctors at SSCD do a comprehensive exam and determine the patient’s treatment plan and put together a package that details what the patient needs in order to be transplanted. It’s very standardized, and it allows Johnson and Winston to determine which difficult patients they need to keep in house, versus those who are medically stable enough to be managed by the volunteer dentists. Freimund again plays a pivotal role by recruiting dentists to volunteer for the program — a task made a little easier by only giving volunteers work they’re fluent in. Winston says, “What’s nice is that our volunteers get to do work that they’re comfortable doing — so if you’re not somebody who extracts teeth or does root canals, we’ll send you a patient who needs fillings. People aren’t put in situations they aren’t familiar with. Also, the treatment that we recommend is what is required to make the patient transplant-ready, nothing else. It’s not fancy, it’s not crowns or implants, but sometimes the volunteers will choose to do additional work. We only ask them to perform the basic work so that they don’t feel pressured to do more.” Since 2010, the system has cleared more than 100 patients, and 32 have received transplants that they likely wouldn’t have without this dental clearance — the program truly changes lives. 

Working with cancer patients
Long ago, the two made a commitment to provide care to any cancer or transplant patient who needed it. These patients’ lives were at risk, and the dental component was key to their long-term health. Both felt that to deny someone care during that time in their lives seemed wrong, so they made the same commitment to all of the cancer and transplant teams that they work with in the area, not just Swedish. They agreed to take all newly-diagnosed patients, regardless of their ability to pay. In doing so, they became a part of the pre-treatment oncology workup – along with seeing a speech pathologist, a dietician, a social worker, and a cardiologist. Johnson explains, “We wanted to make sure that we were part of that process so that we could get in on the front end of their cancer treatment. We saw the results of people who hadn’t had dentistry in the beginning, and the results were often disastrous.”

A critical element of this process is educating patients about what they can expect — for example, how radiation can affect their salivary glands and the rate at which their teeth decay, even how important stretching can be as a preventative measure. Johnson explains, “The worst-case cancer scenario is when someone has had IV bisphosphonates for breast cancer yet has a mouthful of severe decay — once they have had those treatments we can’t take out teeth because the bone won’t heal. And so we sometimes we end up having to do root canals on little remnants of teeth — it’s a disastrous situation. That’s why we think the work with them is so critical.” Dr. Upendra Parvathaneni of the Seattle Cancer Care Alliance says, “Over the years, they have consistently provided quality and timely services, which is very important with these patients. We use them as the primary referral source for dental clearance because they have worked with so many cancer patients that they understand radiation issues. It’s a different dimension than a typical dental practice. They see at least 100 of my patients a year, and about 250 in total through our head and neck service.”

In fact, Johnson, Winston and Parvathaneni worked together to develop a stent for use in radiation therapy with cancer patients, allowing them to displace the oral structures that don’t have to be in the radiation field during treatment. They published a paper on how to manufacture the devices and hope that other oncologists around the country will use the devices in their treatment of head and neck cancers. It gives practitioners day-to-day stability of the target that they’re treating and allows them to spare oral tissues. “It’s a neat little idea, a cheap device to reduce toxicity,” Parvathaneni says, “Fewer salivary glands are affected by the radiation and more taste buds are spared. It’s in keeping of our mission to treat the needs of patients first.” Winston and Johnson are proud of the work they do on behalf of cancer patients — it’s life-changing work and allows them to “help people on the front end so their lives are better in the long run,” as Johnson says.

Golden Ticket Program
 As all dentists know, Emergency Departments are constantly flooded with dental patients — many of whom do not need to be there. Frustrated ED docs usually provide painkillers, antibiotics, and a list of dentists who take underfunded patients. Often though, the list includes resources who only accept a particular patient population, and it makes finding an appointment difficult in reality. ED docs never know if their patients will get care, or be back again with the same issue — and that is not a quality solution. Winston and Johnson knew that the key was getting patients definitive care, not just the promise of care, so they partnered with Dr. Marty Leiberman, who was Dental Director of Neighborcare at the time, to create the Golden Ticket program. They developed a care plan that begins once the ED doc assesses the situation and ascertains that the patient is not in danger. (The emergent/endangered patients are seen ‘round the clock by an attending and a Swedish GPR resident who are on call.) Non-emergent patients are given a “Golden Ticket” that allows them to be seen at a nearby Neighborcare clinic the next morning. Vander Beek says, “It’s an emergency room diversion program, but it’s a cost-saving program for all of us. It’s very patient-focused, which is a key to any collaboration we’re involved with – we need to determine the benefit to the patient. It creates a clear pathway for the patient and the providers. Our philosophy is meeting the patients where they are, and Bart and Amy have been really easy to work with because they have the same philosophy and goals.”

Winston and Johnson have trained attending ED docs to give local anesthetic, allowing them to numb the patient and get them out of pain, saving the hospital the cost and trouble of prescribing narcotic painkillers. The program is simple and effective, and could easily be duplicated in any city where there is a CHC near a hospital ED, although it would be beneficial to have a GPR close by to handle the truly emergent cases. Winston and Johnson are eyeing other counties as possible sites for a similar program. Data mined over an 18-month period show only one repeat patient in that entire time, so while they can’t prevent that initial visit, they can keep the patients from coming back by addressing the problems quickly and definitively.

Reconstructive team - their newest venture
Because they do so much work with cancer patients, Johnson and Winston have seen them evolve from cancer victims to cancer survivors, but unfortunately often with debilitating results like severe trismus, and cancer-eradication surgeries that can include removing half the patient’s tongue and jaw resections — intense, and sometimes disfiguring surgeries. Their lives are spared at the cost of their countenance. Their quality of life can be extremely poor, and dental reconstruction is not a covered benefit under the current healthcare system, in part because the cost can easily top $50,000. Winston says, “It’s a complicated problem, and it’s interesting to me that medical insurance will think nothing of paying for breast reconstruction after a mastectomy, but when it’s someone’s mouth or face they’re less inclined to pay for anything. Medical insurances typically consider it a dental issue and won’t cover it, dental insurance covers $2,000 at best, and patients are caught in this incredibly difficult situation where they have no options. Even if you’re someone with a solid income, coming up with that kind of money is impossible.” 

As general dentists, a good portion the treatment is beyond their scope of care, but because of the work they do, they were able to assemble a crack team of experts including three oral maxillofacial surgeons, a plastic surgeon, an ENT surgeon, and a maxillofacial prosthodontist. Just as they do with transplant patients, the team puts together a presentation that includes the patient’s picture, radiographs, CT scans and pertinent information about the patient, including medical history. Johnson elaborates, “We have a room full of incredibly bright, talented experts, and we collectively determine a plan to put the person back together and make them functional again. It is just amazing to watch the team interact, hear the kinds of things they can do from the different perspectives.” From this discussion they develop a treatment plan and figure out who will do what, what the sequence is, and what the cost will be, and then Winston sets out writing grants for the patient. It’s a time-consuming process, and while they have found organizations that are willing to cover people who are cancer survivors with medical/dental financial hardships, it doesn’t always get approved. Says Winston, “We present a very thoughtful sequence of care. We tell these organizations what we expect, and then when we’re done, we send the organization pictures of the patient showing the outcomes. As of right now, we have gotten four people through the system. The impact it has made on those individual’s lives is huge – they’ve gone from not being able to eat anything but yogurt to being able to chew real food, they’re no longer embarrassed of their appearance.” While the program’s scale is small, the individual impact is immeasurable. Time, not desire, is the enemy with this program — writing grants is incredibly laborious. Ultimately, they’d like to see the program put through 10-20 patients a year – it’s a win-win for both patients and providers, Winston says, “We have an amazing team that wants to do this, all of whom were trained to do these higher-level surgeries. Not many patients can afford it, so the providers haven’t been able to do all the things they enjoy. The doctors get to do some really cool surgeries, and the patients get their mouths reconstructed.”

On the horizon
    The pair has a few new GPR and AEGD residencies on the horizon, and they’ll continue to nurse the reconstructive project. Their biggest goal — one that they don’t yet know how to attack because of the enormity of the problem, is to get special needs developmentally-disabled patients better access to care in our state. The issue is primarily fiscal – the patients are so profoundly disabled that they cannot possibly support themselves financially and are completely dependent on state resources — and there is not enough money budgeted to cover them. Plus, they usually require advanced care such as IV sedation or general anesthesia to do a good job, and that’s what Winston and Johnson want. Says Winston, “It’s such a huge problem that we don’t know how to tackle it — there isn’t an obvious solution or someone probably would have already found it.” 
    If all of this is not enough, as the director of Hospital Dentistry at Swedish, Winston is involved with creating a regional center for orthognathic surgery and is working closely with the WSDA and its Task Force on Public Policy Development to research expanding existing residency programs in our state. Oh, and Winston has decided to squeeze in an MBA at OHSU in September. She explains, “I feel like having some formal education about the health care system would be extremely beneficial. Our profession is under a lot of stress from insurance companies and student debt, and there are going to be changes forced upon dentists. It’s very hard for me to not engage – I love the process of solving problems. I don’t see us as necessarily charitable, altruistic do-gooders, we’re problem solvers. Because of our involvement with Hospital Dentistry, we’re in a position to identify problems in ways that others may not, and we’re in a position to solve problems because we have the resources. It’s our responsibility.” And while Johnson mostly agrees with her statement, he can’t sit back without giving Winston a gentle ribbing, saying “We’re willing to give away the free care and our life energy because it does feel good to take care of these patients and teach residents to do the same. Yes, we’re absolutely problem solvers, but I think we’re a little on the compassionate side, too.” 
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