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BUILDING ON OUR ACCOMPLISHMENTS
E D U C AT I O N
STORY
BUILDING ON OUR ACCOMPLISHMENTS JAMES E. KENNEDY, D.D.S., M.S.
“The future is purchased by the present.”—Samuel Johnson
T
he beginning of a new century affords a special opportunity to reflect on the past and look forward to the future. A dentist who left practice in 1899 and was suddenly transported to 1999 would find a profession that little resembles his or her own experience of a century ago. The acceptance of local anes-
thesia, fluoride as a central element in preventive strategies, specialists, the concepts of focal infection and antisepsis, the demise of proprietary schools of dentistry and the existence of 55 university-based schools of dental medicine are but a few of the changes he or she would find.1 But
despite the scope and magnitude of these developments, when viewed from the perspective of a hundred years, change in dentistry—and certainly in dental education—has been slow, measured and incremental.
During the 20th century, major changes in dental education have been the result of different forces. For example, the discovery of the benefits of fluoride allowed the creation of new preventive strategies, and prevention became a major focus of dental education and practice. The federal government, through the Health Professions Educational Act of 1963 and the Comprehensive Health Manpower Act of 1971, committed millions of dollars to pursuing an agenda of expansion. New schools were constructed, predoctoral enrollments increased, and com-
munity-based programs were developed. Change in dental education also has been fostered by accreditation and the changing expectations of dental schools’ parent institutions as dentistry strove for recognition as a university discipline. And, yes, dental education also responded to what might be termed “educational fads” for fear of being out of step. Whether one considers predoctoral, graduate, continuing or allied dental education, each has the dental school as a common denominator. Granted, dental education takes place at other venues,
ABSTRACT
COVER
Background and Overview. There are at least five forces— knowledge, finances, diversity, faculty and government—that have the potential to change the current model of dental education significantly in the new century. The author explores these forces and attempts to project their future impact on dental education and the profession. Conclusions. Our understanding of the etiology and pathogenesis of oral diseases will increase, though likely not enough to facilitate the elimination of either dental caries or adult-onset periodontitis. A mandatory year of additional formal education in the form of a postgraduate residency will become necessary. Current trends in the sources of revenue supporting dental education will continue, and dental education will face a financial crisis. The changing ethnic and racial diversity of the United States and the dental work force will require curricular changes to prepare students to meet the oral health needs of diverse populations. The current shortage of full-time dental faculty members will continue, and dental schools will need to redefine what it means to be a faculty member. Finally, the continuing decline in the dentist:population ratio and a peak in the actual number of active dentists will cause government to again question the adequacy of the dental work force. Practice Implications. Academic dentistry faces a new century with new challenges, all of which have implications for current and future dental practitioners. The extent to which these challenges are successfully met will depend on the degree to which those with a vested interest in a thriving profession come together for the mutual benefit of all.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1729
COVER STORY but what affects the dental school and alters the basic model of dental education eventually will affect all who provide this education regardDentistry will come less of the setting. Today, there are at least five forces to embrace the need whose present trends portend for additional formal a potential to change dental education significantly in the education in the 21st century: knowledge, form of a mandatory finances, diversity, faculty and year of postgraduate government. What follows is an assessment of these trends education. and a projection of their future impact.
DENTISTRY
Education
2000
KNOWLEDGE
The predoctoral dental curriculum of today bears a striking resemblance to the structure called for in 1918 by the Dental Education Council of America, the predecessor of the American Dental Association’s Council on Dental Education, as set forth in the requirements for a Class “A” dental school.2 The four-year curriculum was to provide 4,400 hours of instruction—roughly 24 percent of it in basic sciences, 3 21 percent in preclinical technique and 55 percent in clinical dental sciences. Today’s 4,926-hour curriculum has shifted the emphasis slightly: basic and behavioral sciences make up roughly 20 percent of the program, preclinical technique 14 percent and clinical sciences roughly 66 percent. Certainly, the content of the curriculum has changed over time as dental science and technology have evolved, but
the basic approach to preparing a dentist to enter practice immediately after graduation has not. How likely is significant change in the future? Drastic change in the dental curriculum will require that at least one of two things occur: a scientific breakthrough that will virtually eliminate caries or adult-onset periodontitis or both, or an extension of the period of formal education required for entry into practice to accommodate the ever-expanding body of knowledge and skills that practitioners need. The former is not beyond the realm of possibility, but even then the time necessary for broadbased implementation and treatment of existing disease would take several decades. The reductions in the prevalence of dental caries and the prevalence and severity of adult-onset periodontitis experienced in the United States over the past 25 years have had little impact on the dental curriculum, since prevalence of disease is irrelevant to the time necessary to acquire the knowledge and skills required to treat the disease. The more likely near-term possibility is that dentistry will come to embrace the need for additional formal education in the form of a mandatory year of postgraduate education, or PGY 1. Such a change in the basic model of dental education has been discussed for some time. In 1995, the Institute of Medicine called for the creation of a number of graduate dental education positions sufficient to accommodate all graduates by 2005; as a result, growth would
TABLE 1
DENTAL SCHOOL REVENUES 1975 AND 1997* (IN MILLIONS OF CURRENT DOLLARS). SOURCE
1975
1997
117.6
413.1
Federal Government
85.6
9.7
Tuition and Fees
51.6
Clinical Services Other
State Government
TOTAL
DIFFERENCE
CHANGE (%)
FACTOR
295.5
251
3.5
-75.9
-89
0.1
353.9
302.3
586
6.9
32.2
241.3
209.1
649
7.5
23.4
141.2
117.8
503
6.0
848.8
273†
310.4
1,159.2
* Fiscal years ending in 1975 and 1997. † Average change.
1730
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
—
COVER STORY occur in general dentistry, and additional positions in the recognized dental specialties would be discouraged.5 In a series of articles reflecting primarily the perspective of dental educators,6 a focused and compelling rationale for a mandatory PGY 1 has been set forth, distilled into two primary points: dan assessment of the competencies (and their underlying knowledge and skills) that a work force dominated by general practitioners will need to meet the oral health needs of the public in the coming century; dan objective assessment of what the predoctoral curriculum realistically can be expected to deliver. Implementation of PGY 1 will require a broader consensus than that now emerging from dental education. Until the dental profession in general, and those responsible for setting the requirements for licensure in the United States in particular, come to the same conclusion, the debate will continue, and dental education will not have the opportunity to comprehensively reconceptualize and restructure the predoctoral curriculum. New knowledge and the opportunity to transmit knowledge are essential antecedents to change. Until one of the major oral diseases is eliminated or PGY 1 is mandatory, change in the predoctoral curriculum will be incremental as science slowly reveals the secrets of the etiology and pathogenesis of oral diseases and their interrelationships with systemic diseases,
DENTAL SCHOOL REVENUES 1975 (PERCENTAGE OF REVENUES). SOURCE
1975
State Government
37.9
Federal Government
27.6
Tuition and Fees
16.6
Clinical Services
10.4
Other
7.5
TOTAL
100
* Fiscal years ending in 1975 and 1997.
2000
FINANCING DENTAL EDUCATION
measure of educa-
The financing of dental educa- tional programs and tion must be considered when their product. speculating about change in dental education. In recent years, attention has been appropriately focused on growing student debt. While revenues from student tuition and fees have increased significantly in the past 20 years, less noticed has been a fundamental shift in the sources of revenue supporting dental education. In the 1974-1975 academic year, or AY, 60 dental schools reported total revenues of $310.4 million from state and federal governments; tuition and fees; patient care; and other sources, such as alumni giving, endowments and other educational revenue.7 In the 1996-1997 AY, 55 schools generated revenues of approximately $1.159 billion from these same sources, a 273 percent increase. More important is the shift in sources of revenue (Table 1). The modest increase in funding from state government and the more than eightfold decrease in federal government support for dental education has AND 1997* been offset by increases of more 1997 than 500 percent 35.6 in tuition and fees, clinic patient 0.8 income and other sources.7,8 In 1975, 30.5 tuition and fees 20.8 and clinic revenue 12.3 together accounted for 27 100 percent of dental school revenues
Education
TABLE 2
DENTISTRY and as new and affordable technology becomes available. Dentistry will move closer to medicine but will not be subsumed by it. Outcomes Outcomes assessment, which is increasingly emphasized, will become assessment, which the standard measure of eduis increasingly cational programs and their emphasized, will product. become the standard
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1731
COVER STORY (Table 2). In 1997, revenues from these same sources provided 51.3 percent of the support for dental education.8 Since 1988, clinic income has Dentistry has prided increased at an average annual rate of 7.7 percent.7 In itself on making a recent years, the rate of dental education increase has begun to decline, while the gap between the available to those higher levels of clinic income with the academic traditionally generated by priability and interest, vate schools and that of public schools has closed. How long not only those will it be before clinic income who can pay. peaks? And what options do dental schools have to enhance this revenue source? There are at least three factors limiting the rate of clinic income: the number and mix of students (predoctoral and graduate), the capacity of physical facilities, and the ability of the patient populations who seek care at a dental school to pay for services. Increasing the number of graduate positions in the specialties would increase revenue and serve as a shortterm solution, but would be counter to maintaining the current balance of general practitioners and specialists. Increasing the number of PGY 1 positions in general practice would serve the same end and support the goal of increasing educational opportunities for graduates but would be limited by the ability to provide sufficient patients. It also would place additional pressure on dental schools to aggressively market their clinical services, bringing them increasingly into direct competition with community practitioners. Construction of new facilities or the acquisition of existing facilities would make sense only if they represented a potential for new revenues in excess of expense. Attempts by dental schools to increase access to care for the undeserved without having adequate funding would only compound the problem.5 Continued increases in tuition and fees—the two sources of dental school revenue that provide more than 50 percent of dental school income—also have their limits. Dentistry has prided itself on making a dental education available to
DENTISTRY
Education
2000
1732
those with academic ability and interest, not only those who can to pay. We must hope that the time will never come when being able to afford dental school will become a basic criterion for admission. High debt is a definite factor—if not yet a major one—influencing a graduate’s plans to pursue graduate education.9 If these two important sources of dental school revenue will soon reach their upper limits, what then? Organized dentistry and dental education together must address the pending financial crisis of dental schools and develop solutions that are consistent with their shared objectives for the profession. As academic health centers increasingly find themselves in financial difficulties, all dental schools will become financially isolated and be expected to become more and more self-supporting, just as many private dental schools are today. The report of the Institute of Medicine5 recommended several strategies. Some, such as “consolidating or merging courses, departments, programs, and even entire schools,” 5 may seem quite radical today. The creation of regional consortia for purchasing equipment and supplies and the sharing of faculty via electronic education are feasible now and have the potential to reduce costs. The future reality may be significantly fewer but larger regional dental schools, with the teaching component of the curriculum delivered centrally by a few faculty members and clinical education taking place at multiple sites located across a region composed of several states. Without the formulation and implementation of broad-based national strategies, dental schools will do what they must to survive. Unfortunately, some options are not consistent with the best interests of the public and the profession, while others have the potential to bring dental school clinical programs into direct competition for patients. Now is the time to address this issue for the benefit of all. DIVERSITY
The racial and ethnic makeup of the United States is undergoing significant change. These changes are seen in the
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY DENTISTRY Asians and Eastern Europeans come to represent an increasing proportion of practicing dentists, it is reasonable to assume they also will seek It is essential that to find an identity and form their own organizations. the profession break Today, the National Dental down the stereoAssociation, the Women’s Dental Association and the typical idea of ethnic Hispanic Dental Association or racial groups have programs to establish treating their own contacts with dental students, counsel them about the benekind. fits of membership and encourage attendance at local and national meetings. A growth in both the number of and membership in national organizations representing various groups of dentists may be inevitable, but it should not be allowed to splinter the profession. If the ADA is to continue to be the voice of dentistry in the next century, including its critical role in dental education, at least two things must happen. First, the ADA must reach out to current and soon-to-be-established ethnicity- , race- and sex-based organizations and seek ways to support and enhance their agendas while promoting the idea that the ADA is the umbrella organization that speaks for all dental practitioners. Dentists represent less than 1 percent of the population of the United States. We cannot afford to be divided. The second needed change is a shared responsibility of dental educators and all who are committed to the principle of quality oral health care for every citizen. The call for increased minority enrollment has been linked in part to a need to meet the needs of underserved minority populations.5 Medicine’s lack of success thus far in seeing enrollments mirror population demographics despite the intense effort of American medical schools12 makes it unlikely that dentistry will succeed. Therefore, it is essential that the profession break down the stereotypical idea of ethnic or racial groups treating their own kind. Dentistry must strive for the day when a patient is comfortable in seeking care from a dentist regardless of either one’s sex, race or national origin.
2000
Education
dental school applicant pool, and the changing characteristics of graduating classes have changed in the past decade as the percentage of whites has decreased and the number of minorities, predominantly Asians, has increased.10 In the 1996-1997 AY, 20 dental schools (36.4 percent) admitted international graduates to the predoctoral program, and 7.7 percent of first-year dental students were citizens of countries other than the United States or Canada.11 For some time, women have composed approximately 35 percent of graduating classes.10 More than 25 percent of training positions in recognized dental specialties and 15.5 percent in general dentistry (general practice residency and advanced education in general dentistry) were held by non-U.S. citizens.9 These changes in the demographics of the U.S. population and the composition of the dental student body have implications for the dental curriculum, dental school clinical programs and the American Dental Association’s interaction with dental education. The predoctoral curriculum must change to prepare students to treat patients whose value systems, experiences with oral health care and beliefs regarding dentistry are different from those of typical dental-school patients of the past. Faculty members must become more aware of and sensitive to the diverse needs of a more racially and ethnically complex student body while the faculty itself becomes more diverse. Unfortunately, it is unlikely that dental education will be at the forefront of this movement; rather, it will follow the slowly developing national recognition and gradually adjust. In the 20th century, the ADA has had a significant influence on dental education through its Council on Dental Education and Commission on Dental Accreditation. The basis for the Association’s role has been, in part, that it represents the overwhelming majority of dentists practicing in the United States. This could change in the next century. Because of necessity or to satisfy a perceived need, blacks, women and Hispanics have formed their own national organizations. As the number of
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1733
COVER STORY THE DENTAL FACULTY
DENTISTRY
2000
Education
Unfortunately, the predictions made more than a decade ago The predictions that dental schools would face a critical shortage of clinical made more than a faculty has come to fruition.13 decade ago that Conservatively, there is a need dental schools would for 200 dentists to become fulltime faculty members each face a critical year,14 a need confirmed by the shortage of faculty National Academy of Sciences.15 Expressed another has come to fruition. way, each year 5 percent of every graduating class would need to embark on the three to five years of postgraduate education necessary to prepare for a career in academic dentistry—at a time when significant deterrents exist to choosing such a career.12 A shortage of faculty is further compounded by the appropriate call to change the present approach to dental education by replacing lectures with seminars and other active learning strategies as a means of developing critical-thinking and problem-solving skills.5 A similar need exists in dental continuing education, with the growing appreciation that practitioners learn better and are more likely to modify practice behavior if given the opportunity to discuss new information with colleagues.16 Such changes would require a greater commitment of facultystudent contact time, as well as time devoted to preparation. At the same time, academic dentistry is increasingly being called on to justify itself as a discipline. The dental school faculty is a component of an academic health center that usually is linked to a research-intensive university, where scholarship—especially that associated with external grant support—is the currency of acceptance. If dental faculty members are to successfully serve the two masters of education and research while clinical faculty members are being seen as a source of needed revenue, then the current faculty paradigm must undergo significant change over the next few decades. The established trend for fewer tenure-track 1734
and more fixed-term nontenured appointments will continue.13 As a means of reducing costs, full-time faculty members will be expected to generate a portion of their school-based salaries. For many more clinical faculty members than is presently the case, compensation will come from a combination of dental school salary and private practice income as the definitions of full-time and part-time faculty are revised. As a result, the proportion of fulltime faculty equivalents represented by part-time faculty will increase from the current 27.4 percent12 to more than 50 percent. Those who do remain in full-time positions will have a narrower responsibility, with primary emphasis in only one of the traditional areas of teaching, service, research and patient care, as the academic department—or the school itself— becomes the unit on which academic productivity is measured. GOVERNMENT
The past 40 years have seen the dramatic impact of government on dental education from at least two perspectives. In the 1960s and 1970s, the so-called “capitation” programs resulted in record predoctoral enrollments, which peaked in 1980 at 22,842 dental students—a sharp contrast to the 17,033 enrolled in 1998.10 The 1980s and 1990s saw a reversal of the federal government’s position relative to the support of dental education with an almost eightfold reduction in funding, from $85.6 million in 1975 to $9.7 million in 1997 (Table 1).7,8 The whipsaw effect of this profound shift in public policy is still being felt. Government has not abandoned its interest in health care or in the goal of universal access to affordable care. In the 21st century, dentistry in general and dental education in particular could be vulnerable to a second round of federal intervention if the dental work force is judged to be inadequate to meet the needs of the public, especially those in underserved and rural areas. The dentist:population ratio has been in decline and currently stands at approximately 56:100,000 people, while the number of active dentists is expected
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY to peak around the turn of the century and then begin a gradual decline. It is not too soon to begin to develop strategies to address concerns about a future shortage of dentists. The research arm of the profession must place greater emphasis on outcomes research and on promoting evidence-based practice as a means of concentrating efforts on the most effective means of preventing and treating oral diseases and thus improving both the quality and efficiency of care. The profession must find additional ways to increase dentists’ efficiency by rethinking the roles of allied dental personnel. Models attempting to estimate the potential to provide care must shift from focusing on number of personnel to the supply of services.5 Dentistry must begin now, rather than to wait for a crisis, to develop the kind of objective information with which sound public policy can be formulated. CONCLUSION
The basic model that has characterized dental education for the better part of the last 70 years is likely to undergo major change in the 21st century. Of the various forces that have the potential to cause change, the expansion of the knowledge that forms the basis of dental practice and the changing ethnic and racial diversity of dental students, dental practitioners and the population of the United States are a virtual certainty. As the knowledge and skills necessary to practice dentistry continue to expand, a consensus will be reached as to the need for one year of additional formal training as a condition for licensure. Increased diversity will require that dental educators think differently about how they prepare students and that the ADA find new ways to meet the needs of various groups of practitioners. If current trends in the financing of dental education continue, dental schools will be faced with
a financial crisis that not only will affect a school’s relationship with the practicing community but also will alter the role of full-time faculty members as generators of revenue. As the dentist:population ratio continues to decline, government again will question the adequacy of the pool of dental professionals. Dentistry must begin soon to develop the objective information needed to serve as the basis for sound public policy. ■ Dr. Kennedy is professor of periodontology and dean emeritus, University of Connecticut, School of Dental Medicine, 263 Farmington Ave., Farmington, Conn. 06030. Address reprint requests to Dr. Kennedy. 1. Asbell MB. Dentistry: a historical perspective. Bryn Mawr, Pa.: Dorrance & Co. Inc.; 1998:174-211. 2. Dental Education Association of America. Minimum requirements for a class “A” dental school. Milwaukee: Dental Education Association of America; 1918. 3. Gies W. Dental education in the United States and Canada (bulletin 19). New York: Carnegie Foundation for the Advancement of Teaching; 1926. 4. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 3. Chicago: American Dental Association; 1999. 5. Institute of Medicine. Dental education at the crossroads. Washington: National Academy Press; 1995. 6. American Association of Dental Schools. Progress toward a mandatory post-graduate year for dentistry. J Dent Educ 1999;63:609-53. 7. Douglass C, Fein R. Financing dental education. J Dent Educ 1995;59:185-202. 8. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 5. Chicago: American Dental Association; 1999. 9. Weaver R. Trends in postdoctoral dental education. J Dent Educ 1999;63:626-34. 10. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 1. Chicago: American Dental Association; 1999. 11. American Dental Association. 1996/97 Survey of predoctoral dental educational institutions. Vol. 2. Chicago: American Dental Association; 1997. 12. Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med 1994;331:472-6. 13. Kennedy JE, Hunt RJ. Meeting the demand for future dental faculty. J Dent Educ 1999;63:89-98. 14. Kennedy JE. Faculty status in a climate of change. J Dent Educ 1990;54:268-72. 15. Hirsh IJ, Stobo JD. Meeting the nation’s needs for biomedical and behavioral scientists. Washington: National Academy Press; 1994. 16. Slotnick HB. How doctors learn: the role of clinical problems across the medical school-to-practice continuum. Acad Med 1996;71: 28-34.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1735
STORY
BUILDING ON OUR ACCOMPLISHMENTS JAMES E. KENNEDY, D.D.S., M.S.
“The future is purchased by the present.”—Samuel Johnson
T
he beginning of a new century affords a special opportunity to reflect on the past and look forward to the future. A dentist who left practice in 1899 and was suddenly transported to 1999 would find a profession that little resembles his or her own experience of a century ago. The acceptance of local anes-
thesia, fluoride as a central element in preventive strategies, specialists, the concepts of focal infection and antisepsis, the demise of proprietary schools of dentistry and the existence of 55 university-based schools of dental medicine are but a few of the changes he or she would find.1 But
despite the scope and magnitude of these developments, when viewed from the perspective of a hundred years, change in dentistry—and certainly in dental education—has been slow, measured and incremental.
During the 20th century, major changes in dental education have been the result of different forces. For example, the discovery of the benefits of fluoride allowed the creation of new preventive strategies, and prevention became a major focus of dental education and practice. The federal government, through the Health Professions Educational Act of 1963 and the Comprehensive Health Manpower Act of 1971, committed millions of dollars to pursuing an agenda of expansion. New schools were constructed, predoctoral enrollments increased, and com-
munity-based programs were developed. Change in dental education also has been fostered by accreditation and the changing expectations of dental schools’ parent institutions as dentistry strove for recognition as a university discipline. And, yes, dental education also responded to what might be termed “educational fads” for fear of being out of step. Whether one considers predoctoral, graduate, continuing or allied dental education, each has the dental school as a common denominator. Granted, dental education takes place at other venues,
ABSTRACT
COVER
Background and Overview. There are at least five forces— knowledge, finances, diversity, faculty and government—that have the potential to change the current model of dental education significantly in the new century. The author explores these forces and attempts to project their future impact on dental education and the profession. Conclusions. Our understanding of the etiology and pathogenesis of oral diseases will increase, though likely not enough to facilitate the elimination of either dental caries or adult-onset periodontitis. A mandatory year of additional formal education in the form of a postgraduate residency will become necessary. Current trends in the sources of revenue supporting dental education will continue, and dental education will face a financial crisis. The changing ethnic and racial diversity of the United States and the dental work force will require curricular changes to prepare students to meet the oral health needs of diverse populations. The current shortage of full-time dental faculty members will continue, and dental schools will need to redefine what it means to be a faculty member. Finally, the continuing decline in the dentist:population ratio and a peak in the actual number of active dentists will cause government to again question the adequacy of the dental work force. Practice Implications. Academic dentistry faces a new century with new challenges, all of which have implications for current and future dental practitioners. The extent to which these challenges are successfully met will depend on the degree to which those with a vested interest in a thriving profession come together for the mutual benefit of all.
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
1729
COVER STORY but what affects the dental school and alters the basic model of dental education eventually will affect all who provide this education regardDentistry will come less of the setting. Today, there are at least five forces to embrace the need whose present trends portend for additional formal a potential to change dental education significantly in the education in the 21st century: knowledge, form of a mandatory finances, diversity, faculty and year of postgraduate government. What follows is an assessment of these trends education. and a projection of their future impact.
DENTISTRY
Education
2000
KNOWLEDGE
The predoctoral dental curriculum of today bears a striking resemblance to the structure called for in 1918 by the Dental Education Council of America, the predecessor of the American Dental Association’s Council on Dental Education, as set forth in the requirements for a Class “A” dental school.2 The four-year curriculum was to provide 4,400 hours of instruction—roughly 24 percent of it in basic sciences, 3 21 percent in preclinical technique and 55 percent in clinical dental sciences. Today’s 4,926-hour curriculum has shifted the emphasis slightly: basic and behavioral sciences make up roughly 20 percent of the program, preclinical technique 14 percent and clinical sciences roughly 66 percent. Certainly, the content of the curriculum has changed over time as dental science and technology have evolved, but
the basic approach to preparing a dentist to enter practice immediately after graduation has not. How likely is significant change in the future? Drastic change in the dental curriculum will require that at least one of two things occur: a scientific breakthrough that will virtually eliminate caries or adult-onset periodontitis or both, or an extension of the period of formal education required for entry into practice to accommodate the ever-expanding body of knowledge and skills that practitioners need. The former is not beyond the realm of possibility, but even then the time necessary for broadbased implementation and treatment of existing disease would take several decades. The reductions in the prevalence of dental caries and the prevalence and severity of adult-onset periodontitis experienced in the United States over the past 25 years have had little impact on the dental curriculum, since prevalence of disease is irrelevant to the time necessary to acquire the knowledge and skills required to treat the disease. The more likely near-term possibility is that dentistry will come to embrace the need for additional formal education in the form of a mandatory year of postgraduate education, or PGY 1. Such a change in the basic model of dental education has been discussed for some time. In 1995, the Institute of Medicine called for the creation of a number of graduate dental education positions sufficient to accommodate all graduates by 2005; as a result, growth would
TABLE 1
DENTAL SCHOOL REVENUES 1975 AND 1997* (IN MILLIONS OF CURRENT DOLLARS). SOURCE
1975
1997
117.6
413.1
Federal Government
85.6
9.7
Tuition and Fees
51.6
Clinical Services Other
State Government
TOTAL
DIFFERENCE
CHANGE (%)
FACTOR
295.5
251
3.5
-75.9
-89
0.1
353.9
302.3
586
6.9
32.2
241.3
209.1
649
7.5
23.4
141.2
117.8
503
6.0
848.8
273†
310.4
1,159.2
* Fiscal years ending in 1975 and 1997. † Average change.
1730
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
—
COVER STORY occur in general dentistry, and additional positions in the recognized dental specialties would be discouraged.5 In a series of articles reflecting primarily the perspective of dental educators,6 a focused and compelling rationale for a mandatory PGY 1 has been set forth, distilled into two primary points: dan assessment of the competencies (and their underlying knowledge and skills) that a work force dominated by general practitioners will need to meet the oral health needs of the public in the coming century; dan objective assessment of what the predoctoral curriculum realistically can be expected to deliver. Implementation of PGY 1 will require a broader consensus than that now emerging from dental education. Until the dental profession in general, and those responsible for setting the requirements for licensure in the United States in particular, come to the same conclusion, the debate will continue, and dental education will not have the opportunity to comprehensively reconceptualize and restructure the predoctoral curriculum. New knowledge and the opportunity to transmit knowledge are essential antecedents to change. Until one of the major oral diseases is eliminated or PGY 1 is mandatory, change in the predoctoral curriculum will be incremental as science slowly reveals the secrets of the etiology and pathogenesis of oral diseases and their interrelationships with systemic diseases,
DENTAL SCHOOL REVENUES 1975 (PERCENTAGE OF REVENUES). SOURCE
1975
State Government
37.9
Federal Government
27.6
Tuition and Fees
16.6
Clinical Services
10.4
Other
7.5
TOTAL
100
* Fiscal years ending in 1975 and 1997.
2000
FINANCING DENTAL EDUCATION
measure of educa-
The financing of dental educa- tional programs and tion must be considered when their product. speculating about change in dental education. In recent years, attention has been appropriately focused on growing student debt. While revenues from student tuition and fees have increased significantly in the past 20 years, less noticed has been a fundamental shift in the sources of revenue supporting dental education. In the 1974-1975 academic year, or AY, 60 dental schools reported total revenues of $310.4 million from state and federal governments; tuition and fees; patient care; and other sources, such as alumni giving, endowments and other educational revenue.7 In the 1996-1997 AY, 55 schools generated revenues of approximately $1.159 billion from these same sources, a 273 percent increase. More important is the shift in sources of revenue (Table 1). The modest increase in funding from state government and the more than eightfold decrease in federal government support for dental education has AND 1997* been offset by increases of more 1997 than 500 percent 35.6 in tuition and fees, clinic patient 0.8 income and other sources.7,8 In 1975, 30.5 tuition and fees 20.8 and clinic revenue 12.3 together accounted for 27 100 percent of dental school revenues
Education
TABLE 2
DENTISTRY and as new and affordable technology becomes available. Dentistry will move closer to medicine but will not be subsumed by it. Outcomes Outcomes assessment, which is increasingly emphasized, will become assessment, which the standard measure of eduis increasingly cational programs and their emphasized, will product. become the standard
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
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COVER STORY (Table 2). In 1997, revenues from these same sources provided 51.3 percent of the support for dental education.8 Since 1988, clinic income has Dentistry has prided increased at an average annual rate of 7.7 percent.7 In itself on making a recent years, the rate of dental education increase has begun to decline, while the gap between the available to those higher levels of clinic income with the academic traditionally generated by priability and interest, vate schools and that of public schools has closed. How long not only those will it be before clinic income who can pay. peaks? And what options do dental schools have to enhance this revenue source? There are at least three factors limiting the rate of clinic income: the number and mix of students (predoctoral and graduate), the capacity of physical facilities, and the ability of the patient populations who seek care at a dental school to pay for services. Increasing the number of graduate positions in the specialties would increase revenue and serve as a shortterm solution, but would be counter to maintaining the current balance of general practitioners and specialists. Increasing the number of PGY 1 positions in general practice would serve the same end and support the goal of increasing educational opportunities for graduates but would be limited by the ability to provide sufficient patients. It also would place additional pressure on dental schools to aggressively market their clinical services, bringing them increasingly into direct competition with community practitioners. Construction of new facilities or the acquisition of existing facilities would make sense only if they represented a potential for new revenues in excess of expense. Attempts by dental schools to increase access to care for the undeserved without having adequate funding would only compound the problem.5 Continued increases in tuition and fees—the two sources of dental school revenue that provide more than 50 percent of dental school income—also have their limits. Dentistry has prided itself on making a dental education available to
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those with academic ability and interest, not only those who can to pay. We must hope that the time will never come when being able to afford dental school will become a basic criterion for admission. High debt is a definite factor—if not yet a major one—influencing a graduate’s plans to pursue graduate education.9 If these two important sources of dental school revenue will soon reach their upper limits, what then? Organized dentistry and dental education together must address the pending financial crisis of dental schools and develop solutions that are consistent with their shared objectives for the profession. As academic health centers increasingly find themselves in financial difficulties, all dental schools will become financially isolated and be expected to become more and more self-supporting, just as many private dental schools are today. The report of the Institute of Medicine5 recommended several strategies. Some, such as “consolidating or merging courses, departments, programs, and even entire schools,” 5 may seem quite radical today. The creation of regional consortia for purchasing equipment and supplies and the sharing of faculty via electronic education are feasible now and have the potential to reduce costs. The future reality may be significantly fewer but larger regional dental schools, with the teaching component of the curriculum delivered centrally by a few faculty members and clinical education taking place at multiple sites located across a region composed of several states. Without the formulation and implementation of broad-based national strategies, dental schools will do what they must to survive. Unfortunately, some options are not consistent with the best interests of the public and the profession, while others have the potential to bring dental school clinical programs into direct competition for patients. Now is the time to address this issue for the benefit of all. DIVERSITY
The racial and ethnic makeup of the United States is undergoing significant change. These changes are seen in the
JADA, Vol. 130, December 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
COVER STORY DENTISTRY Asians and Eastern Europeans come to represent an increasing proportion of practicing dentists, it is reasonable to assume they also will seek It is essential that to find an identity and form their own organizations. the profession break Today, the National Dental down the stereoAssociation, the Women’s Dental Association and the typical idea of ethnic Hispanic Dental Association or racial groups have programs to establish treating their own contacts with dental students, counsel them about the benekind. fits of membership and encourage attendance at local and national meetings. A growth in both the number of and membership in national organizations representing various groups of dentists may be inevitable, but it should not be allowed to splinter the profession. If the ADA is to continue to be the voice of dentistry in the next century, including its critical role in dental education, at least two things must happen. First, the ADA must reach out to current and soon-to-be-established ethnicity- , race- and sex-based organizations and seek ways to support and enhance their agendas while promoting the idea that the ADA is the umbrella organization that speaks for all dental practitioners. Dentists represent less than 1 percent of the population of the United States. We cannot afford to be divided. The second needed change is a shared responsibility of dental educators and all who are committed to the principle of quality oral health care for every citizen. The call for increased minority enrollment has been linked in part to a need to meet the needs of underserved minority populations.5 Medicine’s lack of success thus far in seeing enrollments mirror population demographics despite the intense effort of American medical schools12 makes it unlikely that dentistry will succeed. Therefore, it is essential that the profession break down the stereotypical idea of ethnic or racial groups treating their own kind. Dentistry must strive for the day when a patient is comfortable in seeking care from a dentist regardless of either one’s sex, race or national origin.
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dental school applicant pool, and the changing characteristics of graduating classes have changed in the past decade as the percentage of whites has decreased and the number of minorities, predominantly Asians, has increased.10 In the 1996-1997 AY, 20 dental schools (36.4 percent) admitted international graduates to the predoctoral program, and 7.7 percent of first-year dental students were citizens of countries other than the United States or Canada.11 For some time, women have composed approximately 35 percent of graduating classes.10 More than 25 percent of training positions in recognized dental specialties and 15.5 percent in general dentistry (general practice residency and advanced education in general dentistry) were held by non-U.S. citizens.9 These changes in the demographics of the U.S. population and the composition of the dental student body have implications for the dental curriculum, dental school clinical programs and the American Dental Association’s interaction with dental education. The predoctoral curriculum must change to prepare students to treat patients whose value systems, experiences with oral health care and beliefs regarding dentistry are different from those of typical dental-school patients of the past. Faculty members must become more aware of and sensitive to the diverse needs of a more racially and ethnically complex student body while the faculty itself becomes more diverse. Unfortunately, it is unlikely that dental education will be at the forefront of this movement; rather, it will follow the slowly developing national recognition and gradually adjust. In the 20th century, the ADA has had a significant influence on dental education through its Council on Dental Education and Commission on Dental Accreditation. The basis for the Association’s role has been, in part, that it represents the overwhelming majority of dentists practicing in the United States. This could change in the next century. Because of necessity or to satisfy a perceived need, blacks, women and Hispanics have formed their own national organizations. As the number of
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COVER STORY THE DENTAL FACULTY
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Unfortunately, the predictions made more than a decade ago The predictions that dental schools would face a critical shortage of clinical made more than a faculty has come to fruition.13 decade ago that Conservatively, there is a need dental schools would for 200 dentists to become fulltime faculty members each face a critical year,14 a need confirmed by the shortage of faculty National Academy of Sciences.15 Expressed another has come to fruition. way, each year 5 percent of every graduating class would need to embark on the three to five years of postgraduate education necessary to prepare for a career in academic dentistry—at a time when significant deterrents exist to choosing such a career.12 A shortage of faculty is further compounded by the appropriate call to change the present approach to dental education by replacing lectures with seminars and other active learning strategies as a means of developing critical-thinking and problem-solving skills.5 A similar need exists in dental continuing education, with the growing appreciation that practitioners learn better and are more likely to modify practice behavior if given the opportunity to discuss new information with colleagues.16 Such changes would require a greater commitment of facultystudent contact time, as well as time devoted to preparation. At the same time, academic dentistry is increasingly being called on to justify itself as a discipline. The dental school faculty is a component of an academic health center that usually is linked to a research-intensive university, where scholarship—especially that associated with external grant support—is the currency of acceptance. If dental faculty members are to successfully serve the two masters of education and research while clinical faculty members are being seen as a source of needed revenue, then the current faculty paradigm must undergo significant change over the next few decades. The established trend for fewer tenure-track 1734
and more fixed-term nontenured appointments will continue.13 As a means of reducing costs, full-time faculty members will be expected to generate a portion of their school-based salaries. For many more clinical faculty members than is presently the case, compensation will come from a combination of dental school salary and private practice income as the definitions of full-time and part-time faculty are revised. As a result, the proportion of fulltime faculty equivalents represented by part-time faculty will increase from the current 27.4 percent12 to more than 50 percent. Those who do remain in full-time positions will have a narrower responsibility, with primary emphasis in only one of the traditional areas of teaching, service, research and patient care, as the academic department—or the school itself— becomes the unit on which academic productivity is measured. GOVERNMENT
The past 40 years have seen the dramatic impact of government on dental education from at least two perspectives. In the 1960s and 1970s, the so-called “capitation” programs resulted in record predoctoral enrollments, which peaked in 1980 at 22,842 dental students—a sharp contrast to the 17,033 enrolled in 1998.10 The 1980s and 1990s saw a reversal of the federal government’s position relative to the support of dental education with an almost eightfold reduction in funding, from $85.6 million in 1975 to $9.7 million in 1997 (Table 1).7,8 The whipsaw effect of this profound shift in public policy is still being felt. Government has not abandoned its interest in health care or in the goal of universal access to affordable care. In the 21st century, dentistry in general and dental education in particular could be vulnerable to a second round of federal intervention if the dental work force is judged to be inadequate to meet the needs of the public, especially those in underserved and rural areas. The dentist:population ratio has been in decline and currently stands at approximately 56:100,000 people, while the number of active dentists is expected
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COVER STORY to peak around the turn of the century and then begin a gradual decline. It is not too soon to begin to develop strategies to address concerns about a future shortage of dentists. The research arm of the profession must place greater emphasis on outcomes research and on promoting evidence-based practice as a means of concentrating efforts on the most effective means of preventing and treating oral diseases and thus improving both the quality and efficiency of care. The profession must find additional ways to increase dentists’ efficiency by rethinking the roles of allied dental personnel. Models attempting to estimate the potential to provide care must shift from focusing on number of personnel to the supply of services.5 Dentistry must begin now, rather than to wait for a crisis, to develop the kind of objective information with which sound public policy can be formulated. CONCLUSION
The basic model that has characterized dental education for the better part of the last 70 years is likely to undergo major change in the 21st century. Of the various forces that have the potential to cause change, the expansion of the knowledge that forms the basis of dental practice and the changing ethnic and racial diversity of dental students, dental practitioners and the population of the United States are a virtual certainty. As the knowledge and skills necessary to practice dentistry continue to expand, a consensus will be reached as to the need for one year of additional formal training as a condition for licensure. Increased diversity will require that dental educators think differently about how they prepare students and that the ADA find new ways to meet the needs of various groups of practitioners. If current trends in the financing of dental education continue, dental schools will be faced with
a financial crisis that not only will affect a school’s relationship with the practicing community but also will alter the role of full-time faculty members as generators of revenue. As the dentist:population ratio continues to decline, government again will question the adequacy of the pool of dental professionals. Dentistry must begin soon to develop the objective information needed to serve as the basis for sound public policy. ■ Dr. Kennedy is professor of periodontology and dean emeritus, University of Connecticut, School of Dental Medicine, 263 Farmington Ave., Farmington, Conn. 06030. Address reprint requests to Dr. Kennedy. 1. Asbell MB. Dentistry: a historical perspective. Bryn Mawr, Pa.: Dorrance & Co. Inc.; 1998:174-211. 2. Dental Education Association of America. Minimum requirements for a class “A” dental school. Milwaukee: Dental Education Association of America; 1918. 3. Gies W. Dental education in the United States and Canada (bulletin 19). New York: Carnegie Foundation for the Advancement of Teaching; 1926. 4. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 3. Chicago: American Dental Association; 1999. 5. Institute of Medicine. Dental education at the crossroads. Washington: National Academy Press; 1995. 6. American Association of Dental Schools. Progress toward a mandatory post-graduate year for dentistry. J Dent Educ 1999;63:609-53. 7. Douglass C, Fein R. Financing dental education. J Dent Educ 1995;59:185-202. 8. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 5. Chicago: American Dental Association; 1999. 9. Weaver R. Trends in postdoctoral dental education. J Dent Educ 1999;63:626-34. 10. American Dental Association. 1997/98 survey of predoctoral dental educational institutions. Vol. 1. Chicago: American Dental Association; 1999. 11. American Dental Association. 1996/97 Survey of predoctoral dental educational institutions. Vol. 2. Chicago: American Dental Association; 1997. 12. Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med 1994;331:472-6. 13. Kennedy JE, Hunt RJ. Meeting the demand for future dental faculty. J Dent Educ 1999;63:89-98. 14. Kennedy JE. Faculty status in a climate of change. J Dent Educ 1990;54:268-72. 15. Hirsh IJ, Stobo JD. Meeting the nation’s needs for biomedical and behavioral scientists. Washington: National Academy Press; 1994. 16. Slotnick HB. How doctors learn: the role of clinical problems across the medical school-to-practice continuum. Acad Med 1996;71: 28-34.
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