- Email: [email protected]
Motivations and future plans of Canadian orthodontic residents
ORIGINAL ARTICLE
Motivations and future plans of Canadian orthodontic residents James Noble,a Nicholas Karaiskos,b and William A. Wiltshirec Winnipeg, Manitoba, and Ottawa, Ontario, Canada Introduction: Our purposes were to investigate factors influencing career choice and to identify future plans of Canadian orthodontic residents. Methods: All orthodontic residents in the 5 Canadian residency training programs were invited to complete an anonymous online survey in November 2006. Data were categorized by demographic variables, and basic statistics including chi-square comparative analyses were performed. Results: Forty-four of the 54 residents in Canada (81.48%) completed the survey. ‘‘Intellectual stimulation/ challenge’’ emerged as the most important factor (40%) influencing the decision to pursue specialty training in orthodontics, followed by a ‘‘passion for orthodontics’’ (29%). The decision to become an orthodontist was made by 42% of respondents while they were in dental school; 33% had decided after completing dental school, and 24% had already decided before starting their dental school studies. Most residents (82%) planned to work in a private practice environment. Only 2 (4.5%) indicated that they will most likely practice primarily in an academic setting. Eighty percent said that they will use self-ligating brackets in private practice, and almost 80% said they will use Invisalign (Align Technology, Santa Clara, Calif). A total of 55% indicated that orthodontic residents should be required to undertake research leading to a masters of science degree as part of their orthodontic program. A total of 77% thought that a 24- to 30-month program was too short to adequately prepare them for private practice. Conclusions: Intellectual stimulation was the major attraction of most applicants to orthodontic programs, and the decision to become an orthodontist was normally made during dental school or even earlier. Most residents intended to enter an urban or suburban private practice after graduation, with few considering academic career choices. Modern techniques such as self-ligating brackets and Invisalign are expected to be popular among future orthodontists in Canada. (Am J Orthod Dentofacial Orthop 2009;136:644-50)
O
rthodontics is a popular postgraduate dental program in Canada. Every year, each of the 5 graduate programs receives 20 to 40 applications per available position, and about 15 new orthodontists graduate. Most of them remain and work in Canada, adding to the current pool of over 600 practicing orthodontic specialists nationwide. The reasons that orthodontic residents chose the specialty, as well as their future career and practice plans,
a Part-time clinical instructor, Department of Preventive Dental Sciences, Division of Orthodontics, Faculty of Dentistry, University of Manitoba, Winnipeg, Manitoba; staff orthodontist, Bloorview Kids Rehab, Toronto, Ontario; orthodontist, Manitoba Centre for Craniofacial Differences, Children’s Hospital, Winnipeg, Manitoba; orthodontist, Children’s Aid Society of Toronto, Toronto, Ontario; private practice, Toronto, Ontario, Canada. b Private practice, Ottawa, Ontario, Canada. c Professor and head, Department of Preventive Dental Sciences, Division of Orthodontics, Faculty of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: James Noble, 75 The Donway West Suite 414, Toronto, ON, M3C 2E9, Canada; e-mail, [email protected]. Submitted, June 2007; revised and accepted, August 2007. 0889-5406/$36.00 Copyright Ó 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.08.037
644
have not previously been investigated in Canada. Two published surveys of orthodontic residents in the United States (US) and 1 in the United Kingdom (UK) have been reported in the literature.1-3 These studies identified job satisfaction, lifestyle, and a good career structure as important variables that residents considered when choosing orthodontics.1,3 Investigating what motivates dental students to pursue orthodontic training might provide insight into the popularity of the specialty in Canada. The 2 US studies and the UK study established that most residents in their respective countries were interested in private practice after graduation, with only a few expressing an interest in academics.1-3 This information could assist Canadian orthodontic educators in recruitment strategies of future residents interested in making academic and research career choices, and provide important information regarding the numbers of residents planning to practice in underserved rural areas. Furthermore, investigating the future practice patterns of orthodontic residents might shed light on how this specialty is evolving. By identifying specific techniques that orthodontic residents plan to use after graduation, educators will know whether their programs are keeping abreast with the latest technological advances
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
in orthodontics and satisfying their residents’ needs. They can then adjust their curricula to ensure that residents graduate with the appropriate knowledge, training, and proficiency in these techniques. We investigated the reasons that Canadian orthodontic residents chose this specialty and their motivations, ambitions, perceptions, and future practice plans. MATERIAL AND METHODS
Ethics approval was obtained to conduct this study from the University of Manitoba Research Ethics Board. The heads of the 5 Canadian orthodontic programs (Universities of Alberta, Manitoba, Montreal, Toronto, and Western Ontario) were contacted, and permission was obtained to contact their residents to complete the survey. All 54 residents enrolled in these orthodontic residency training programs were sent an e-mail with an online link and were invited to complete an anonymous, 41-item survey in November 2006; most questions were in multiple-choice format or required 1-line answers. Reminders were also sent on several occasions to those who did not complete the survey to increase participation. The survey was completed in an online program that sent a personalized link to each resident’s e-mail to prevent respondents from completing the survey more than once. No personal information was collected to ensure the respondents’ privacy and anonymity. The survey was divided into sections including demographics, reasons for choosing orthodontics, evaluation of the program, and future directions. The survey data were collected into an Excel spreadsheet (Microsoft, Redmond, Wash) and categorized by demographic variables. Basic statistics and comparative analyses by using chi-square testing were undertaken between sex and age groups. RESULTS
A total of 47 of the 54 (87%) orthodontic residents started the survey, and 44 (81%) completed it. Of the respondents, 30 (64%) were male, and 17 (36%) were female; most were in the 25 to 34 years of age category. Table I gives the sex, age, and the year of program of the residents who started the survey. Chi-square analysis showed no significant difference between age categories and between the sexes (P .0.05) for any categories of results. The most common reasons why Canadian residents chose orthodontics as a career was intellectual stimulation (89%) and a passion for orthodontics (69%). Working with younger patients (62%) and work flexibility (49%) were also identified as important factors (Fig 1). When asked what the single most important fac-
Table I.
645
Demographics of survey respondents
Respondents Age (y) \25 25-30 30-34 35-39 .40 Sex Male Female Year in program 1 2 3
Number (%)
0 (0) 23 (48.9) 23 (48.9) 1 (2.1) 0 (0) 30 (63.8) 17 (36.2) 17 (36.2) 18 (38.3) 12 (25.5)
tor was for choosing orthodontics, similar identifiers were obtained. Among the single most important reasons identified were intellectual stimulation (40%), a passion for orthodontics (29%), and having enjoyed orthodontics courses in dental school (6.7%) (Fig 2). Most residents (42%) stated that they made the decision to pursue orthodontics as a specialty while they were in dental school, 33% decided after dental school, and 24% knew before entering dental school that they wanted to be an orthodontist (Fig 3). When asked about their future plans after graduation, most residents indicated that they intended to practice orthodontics as an associate in the private sector (44%). Twenty-two percent stated that they intended to buy an existing orthodontic practice, and 13% planned to start a new orthodontic practice. Only 4% indicated that they intended to pursue a full-time research and teaching career (Table II). Most residents (66%) indicated that they planned to practice in an urban or suburban setting, and 9% planned to practice in an inner city. No residents were considering practicing in a rural location. A large majority of residents (82%) indicated that they planned to work in a private practice, whereas 9% said they would practice in a combination of community and academic settings. Only 5% said they would primarily work in an academic setting, and none was considering working primarily in a community setting. Forty-three percent said that they wanted to work in a group practice, with 30% in a solo practice and 27% undecided. All residents responded that they intended to be involved in direct patient care, as opposed to a purely research career. Most residents (84%) intend to practice full time (more than 3 days per week), and 9% intend to practice part-time (less than 3 days per week). Three of the 4 residents who said they would practice part-time were men. After graduation, most residents (95%) planned to stay in Canada. The most popular cities where they
646
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
Fig 1. Response to the question: what were the main factors influencing your decision to pursue an orthodontic residency training program? Residents could select all answers that applied.
Fig 2. Response to the question: what was the single most important factor influencing your decision to pursue an orthodontic residency training program?
wished to live and work were Montreal, Toronto, and Vancouver (Table III). When asked what percentage of time they would dedicate to either clinical or didactic research, 32% indicated no involvement, 32% were unsure, 30% planned to use 25% of their time, and 7% wanted to spend 50% or more of their time on research (Fig 4).
Regarding the treatment of patients with cleft lip and palate and craniofacial anomalies in their practice, 30% were considering doing so, and 14% were not; 48% said maybe, and 9% were unsure. A total of 80% were planning to use self-ligating brackets in their practice; 11% said maybe, 7% were unsure, and only 2% said they would not. When asked
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
Noble, Karaiskos, and Wiltshire
647
Fig 3. Response to the question: when did you decide to pursue an orthodontics training program?
whether they planned to use Invisalign (Align Technology, Santa Clara, Calif), 80% said they would, 16% said maybe, 5% were unsure, and none said that they would not. The respondents’ views concerning the importance of research in the program and the attainment of a master’s of science degree indicated that 55% were in favor, 23% said maybe, 14% were opposed, and 9% were unsure. When asked their opinion whether a shortened 24to 30-month orthodontic training program adequately prepares residents, 77% said no, and 23% said yes. DISCUSSION
There has never been a published survey of Canadian orthodontic residents. The limitation of this study is that it does not include residents who are training in the US or elsewhere and plan to move to Canada to practice orthodontics after graduation. The literature includes 2 surveys of residents from the US published over the past 13 years1,2 and a survey of residents in the UK.3 Keith and Proffit1 published a survey of orthodontic residents attending the Graduate Resident’s Orthodontic Conference and obtained responses from 168 residents, or 81% of those attending. Bruner et al2 conducted a similar study at the same meeting in 2003 in addition to mailing a survey; they obtained participation from 330 residents, for a response
rate of 77%; this represented 46% of US orthodontic residents. Keith et al3 also conducted a survey of orthodontic residents in the UK and obtained responses from 57 residents—a response rate of 64%. Our response rate of 81.48% was comparable with that of Keith and Proffit1 of 81% in the US and was higher than the other studies in the US and the UK. Keith and Proffit1 found that the most common reason for US residents to choose orthodontics as a career was expected future job satisfaction (89.7%). They also found that 13.7% chose orthodontics as a career because they were dissatisfied with general dentistry. Keith et al3 found that the most common reason for UK residents to choose orthodontics as a career was also expected job satisfaction (93%). Other reasons from that study included lifestyle (39%), good career structure (44%), no ‘‘on call’’ (33%), financial security (25%), dissatisfaction with general dentistry (21%), and an alternative to oral surgery (18%). We found that Canadian orthodontic residents decided to pursue a career in orthodontics because of intellectual stimulation, a passion for orthodontics, working with younger patients, workload flexibility and predictability, earning potential, and positive dental school experience in orthodontics. Intellectual stimulation and a passion for the specialty are probably closely related to an expectation for ‘‘future job satisfaction,’’ which would dovetail with the main reason that residents choose orthodontics
648
Noble, Karaiskos, and Wiltshire
Table II.
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
Future plans of orthodontic residents
Plan Practice orthodontics as an associate Practice orthodontics by buying into an existing practice Practice orthodontics by starting a new practice Apply for fellowship training in Canada Pursue a full-time research and teaching career Undecided
Percent 44.4 22.2 13.3 2.2 4.4 13.3
in Canada, the UK, and the US. Canadian residents also identified with UK residents with respect to career structure, workload flexibility and predictability, and earning potential of their future career. Although orthodontic practice might differ in the UK and North America, there nevertheless appears to be a common thread in residents’ perceptions in the 3 countries. The multiplechoice options offered to Canadian residents were different from those in the previous studies; this makes it difficult to compare the studies directly. In terms of future plans after graduation, Keith and Proffit1 found that 84% of residents intended to enter private practice, with about 50% planning to establish a solo practice or immediately buying in as a partner, and the other 50% expecting to enter an associateship type of practice. Unfortunately, only 6% of the respondents planned to teach. Bruner et al2 found similar results: 82% of the residents indicated that they intended to enter private practice after graduation, only 3% had plans for academia, and 4% considered either academia or something else. Interestingly, 40% reported that they would be interested in full-time academics if the salaries at universities improve. Orthodontic residents in the UK had similar responses, with only 7% indicating an interest in an academic career after graduation. Similar results were found among Canadian orthodontic residents, with 82% indicating that they intend to work in a private practice. Also, after graduation, 45% intended to become an associate in an existing practice, 13% planned to start their own practice, and 23% planned to buy an existing practice. Only 2 Canadian orthodontic residents said that they were interested in pursuing an academic career. This study further confirms the concerns of educators and professional organizations that the future of orthodontic education is in a crisis situation because of the lack of full-time orthodontic professors.4-12 The specialty of orthodontics in Canada, the US, and the UK is not immune to the concerns of the dental profession regarding the ability to recruit and retain residents who will eventually opt to become full-time, tenured academics. Most residents stated that they plan to practice in major cities, and none said that he or she planned to
Table III. Where Canadian orthodontic residents plan to practice when they graduate (n 5 44) City Montreal Canada (city not specified) Unsure Toronto Vancouver Outside Canada Calgary Ottawa Halifax Winnipeg Edmonton
Number 10 8 8 7 3 3 2 1 1 1 1
practice in a smaller city or a rural area. This might indicate a future need for orthodontists in these potentially underserviced areas. Most residents intend to work more than 3 days per week. No significant difference was found between sex and the decision to work full or part time. It might therefore be a generalized misconception that there are more part-time female orthodontists than their male counterparts. An interesting finding of our study was that an overwhelming number of residents indicated that they plan to use self-ligating brackets and Invisalign after graduation. This shows that graduate orthodontic programs are potentially fertile grounds for stimulating the acceptance of modern orthodontic technologies, and thus the future use of bracket systems and techniques by residents when they enter private practice, based on their experiences in the graduate program. Thirty percent of the residents said they plan to care for patients with cleft lip and palate and craniofacial anomalies in their practice. This shows altruism from some graduating orthodontic residents, despite the potentially difficult, long-lasting care and often minimal financial benefit of treating these patients. However, the 70% of residents not planning to treat these patients might be reluctant because of a lack of exposure to these patients during their residency and not necessarily from a lack of altruism. Only 1 Canadian resident indicated an interest in pursuing fellowship training in either Canada or the US; the assumption was that the fellowship program would be in the treatment of patients with cleft lip and palate or craniofacial syndromes. Because most craniofacial deformities are either faculty- or hospital-based, it is a looming problem that, with retiring full-time faculty with expertise in this area, the future availability of services could be at risk.
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
649
Fig 4. Amount of time (%) residents plan to dedicate to didactic or clinical research (n 5 44).
Most residents believe that an orthodontic training program should have a research-based master’s of science component. An overwhelming number of respondents thought that a shorter orthodontic residency training program of only 24 to 30 months is not adequate preparation. However, all Canadian orthodontic training programs are at least 35 or 36 months long, and bias is possible in their perception. An extended 35- or 36-month program with a research component, when offered in American and Canadian accredited programs, is supported because of the increased capacity for critical analysis and the objective evaluation of new scientific technological advancements.13 Furthermore, a 3-year program would provide for more clinical, didactic, and research time and raise clinical understanding and standards, because students see more patients and be expected to start and finish them, as well as follow them through several months of retention. However, even though residents favor a longer orthodontic program combined with a research component, they nevertheless failed to indicate that they were more interested in an academic career than orthodontic residents in the US, where there are shorter 24- to 30-month programs. This might indicate that a longer program combined with a research component does not guarantee, as one might expect, that more orthodontic residents will be produced with a higher affinity for research and are thus more motivated to pursue an
academic career. Selection committees for graduate orthodontic programs might need to rethink their selection strategies if they need to train clinical orthodontists with a research-based degree who are targeted to eventually fill the academic void and assist in alleviating the current crisis in orthodontic recruitment and retention. CONCLUSIONS
1.
2.
3.
4.
5.
The appeal of intellectual stimulation is the most common motivating factor for Canadian dental students who choose to specialize in orthodontics. Most Canadian orthodontic residents will use modern techniques such as self-ligating brackets and Invisalign after graduation. Canadian orthodontic programs might find an exacerbation of the shortage of clinically based orthodontic researchers and full-time academics in the future and should consider measures to prevent this. Most orthodontic residents intend to enter urban or suburban private practices after graduation, and rural areas are at an increasing risk of being underserviced. Canadian orthodontic residents believe that 24- to 30-month orthodontic residency programs do not adequately prepare them for an orthodontic career and favor longer 35- to 36-month programs with a research-based or master’s of science component.
650
Noble, Karaiskos, and Wiltshire
REFERENCES 1. Keith O, Proffit WR. Orthodontic training: the residents’ perspective. Am J Orthod Dentofacial Orthop 1994;106:649-53. 2. Bruner MK, Hilgers KK, Silveira AM, Butters JM. Graduate orthodontic education: the residents’ perspective. Am J Orthod Dentofacial Orthop 2005;128:277-82. 3. Keith O, Stevens CD, Proffit WR, O’Brien KD. A survey of the opinions of orthodontic specialist trainees in the U.K. Br J Orthod 1997;24:163-7. 4. Meskin LH. Those who can, do. J Am Dent Assoc 2000;13: 428-32. 5. Livingston HM, Dellinger TM, Hyde JC, Holder R. The aging and diminishing dental faculty. J Dent Educ 2004;68:345-54. 6. Nunn PJ, Gadbury-Amyot CC, Battrell A, Bruce SI, Hanlon LL, Kaiser C, et al. The current status of allied dental faculty: a survey report. J Dent Educ 2004;68:329-44.
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
7. Flores-Mir C. Dental faculty shortage in the United States and Canada: are there solutions? J Can Dent Assoc 2007;72:725-6. 8. Noble J. Dental faculty shortage. J Can Dent Assoc 2007;72: 870. 9. Lindauer SJ, Peck SL, Tufekci E, Coffey T, Best AM. The crisis in orthodontic education: goals and perceptions. Am J Orthod Dentofacial Orthop 2003;124:480-7. 10. Larson B. Faculty recruitment and retention: challenge or crisis. Am J Orthod Dentofacial Orthop 1998;113:122-3. 11. Haden ND, Beemsterboer RG, Weaver RG, Valachovic RW. Dental school faculty shortages increase: an update on future dental school faculty. J Dent Educ 2000;64:657-73. 12. Trotman CA, Bennett E, Scheffler N, Tulloch JC. Faculty recruitment, retention, and success in dental academia. Am J Orthod Dentofacial Orthop 2002;122:2-8. 13. Sinclair PM, Alexander RG. Orthodontic graduate education survey. Am J Orthod 1984;85:175-81.
Motivations and future plans of Canadian orthodontic residents James Noble,a Nicholas Karaiskos,b and William A. Wiltshirec Winnipeg, Manitoba, and Ottawa, Ontario, Canada Introduction: Our purposes were to investigate factors influencing career choice and to identify future plans of Canadian orthodontic residents. Methods: All orthodontic residents in the 5 Canadian residency training programs were invited to complete an anonymous online survey in November 2006. Data were categorized by demographic variables, and basic statistics including chi-square comparative analyses were performed. Results: Forty-four of the 54 residents in Canada (81.48%) completed the survey. ‘‘Intellectual stimulation/ challenge’’ emerged as the most important factor (40%) influencing the decision to pursue specialty training in orthodontics, followed by a ‘‘passion for orthodontics’’ (29%). The decision to become an orthodontist was made by 42% of respondents while they were in dental school; 33% had decided after completing dental school, and 24% had already decided before starting their dental school studies. Most residents (82%) planned to work in a private practice environment. Only 2 (4.5%) indicated that they will most likely practice primarily in an academic setting. Eighty percent said that they will use self-ligating brackets in private practice, and almost 80% said they will use Invisalign (Align Technology, Santa Clara, Calif). A total of 55% indicated that orthodontic residents should be required to undertake research leading to a masters of science degree as part of their orthodontic program. A total of 77% thought that a 24- to 30-month program was too short to adequately prepare them for private practice. Conclusions: Intellectual stimulation was the major attraction of most applicants to orthodontic programs, and the decision to become an orthodontist was normally made during dental school or even earlier. Most residents intended to enter an urban or suburban private practice after graduation, with few considering academic career choices. Modern techniques such as self-ligating brackets and Invisalign are expected to be popular among future orthodontists in Canada. (Am J Orthod Dentofacial Orthop 2009;136:644-50)
O
rthodontics is a popular postgraduate dental program in Canada. Every year, each of the 5 graduate programs receives 20 to 40 applications per available position, and about 15 new orthodontists graduate. Most of them remain and work in Canada, adding to the current pool of over 600 practicing orthodontic specialists nationwide. The reasons that orthodontic residents chose the specialty, as well as their future career and practice plans,
a Part-time clinical instructor, Department of Preventive Dental Sciences, Division of Orthodontics, Faculty of Dentistry, University of Manitoba, Winnipeg, Manitoba; staff orthodontist, Bloorview Kids Rehab, Toronto, Ontario; orthodontist, Manitoba Centre for Craniofacial Differences, Children’s Hospital, Winnipeg, Manitoba; orthodontist, Children’s Aid Society of Toronto, Toronto, Ontario; private practice, Toronto, Ontario, Canada. b Private practice, Ottawa, Ontario, Canada. c Professor and head, Department of Preventive Dental Sciences, Division of Orthodontics, Faculty of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: James Noble, 75 The Donway West Suite 414, Toronto, ON, M3C 2E9, Canada; e-mail, [email protected]. Submitted, June 2007; revised and accepted, August 2007. 0889-5406/$36.00 Copyright Ó 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.08.037
644
have not previously been investigated in Canada. Two published surveys of orthodontic residents in the United States (US) and 1 in the United Kingdom (UK) have been reported in the literature.1-3 These studies identified job satisfaction, lifestyle, and a good career structure as important variables that residents considered when choosing orthodontics.1,3 Investigating what motivates dental students to pursue orthodontic training might provide insight into the popularity of the specialty in Canada. The 2 US studies and the UK study established that most residents in their respective countries were interested in private practice after graduation, with only a few expressing an interest in academics.1-3 This information could assist Canadian orthodontic educators in recruitment strategies of future residents interested in making academic and research career choices, and provide important information regarding the numbers of residents planning to practice in underserved rural areas. Furthermore, investigating the future practice patterns of orthodontic residents might shed light on how this specialty is evolving. By identifying specific techniques that orthodontic residents plan to use after graduation, educators will know whether their programs are keeping abreast with the latest technological advances
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
in orthodontics and satisfying their residents’ needs. They can then adjust their curricula to ensure that residents graduate with the appropriate knowledge, training, and proficiency in these techniques. We investigated the reasons that Canadian orthodontic residents chose this specialty and their motivations, ambitions, perceptions, and future practice plans. MATERIAL AND METHODS
Ethics approval was obtained to conduct this study from the University of Manitoba Research Ethics Board. The heads of the 5 Canadian orthodontic programs (Universities of Alberta, Manitoba, Montreal, Toronto, and Western Ontario) were contacted, and permission was obtained to contact their residents to complete the survey. All 54 residents enrolled in these orthodontic residency training programs were sent an e-mail with an online link and were invited to complete an anonymous, 41-item survey in November 2006; most questions were in multiple-choice format or required 1-line answers. Reminders were also sent on several occasions to those who did not complete the survey to increase participation. The survey was completed in an online program that sent a personalized link to each resident’s e-mail to prevent respondents from completing the survey more than once. No personal information was collected to ensure the respondents’ privacy and anonymity. The survey was divided into sections including demographics, reasons for choosing orthodontics, evaluation of the program, and future directions. The survey data were collected into an Excel spreadsheet (Microsoft, Redmond, Wash) and categorized by demographic variables. Basic statistics and comparative analyses by using chi-square testing were undertaken between sex and age groups. RESULTS
A total of 47 of the 54 (87%) orthodontic residents started the survey, and 44 (81%) completed it. Of the respondents, 30 (64%) were male, and 17 (36%) were female; most were in the 25 to 34 years of age category. Table I gives the sex, age, and the year of program of the residents who started the survey. Chi-square analysis showed no significant difference between age categories and between the sexes (P .0.05) for any categories of results. The most common reasons why Canadian residents chose orthodontics as a career was intellectual stimulation (89%) and a passion for orthodontics (69%). Working with younger patients (62%) and work flexibility (49%) were also identified as important factors (Fig 1). When asked what the single most important fac-
Table I.
645
Demographics of survey respondents
Respondents Age (y) \25 25-30 30-34 35-39 .40 Sex Male Female Year in program 1 2 3
Number (%)
0 (0) 23 (48.9) 23 (48.9) 1 (2.1) 0 (0) 30 (63.8) 17 (36.2) 17 (36.2) 18 (38.3) 12 (25.5)
tor was for choosing orthodontics, similar identifiers were obtained. Among the single most important reasons identified were intellectual stimulation (40%), a passion for orthodontics (29%), and having enjoyed orthodontics courses in dental school (6.7%) (Fig 2). Most residents (42%) stated that they made the decision to pursue orthodontics as a specialty while they were in dental school, 33% decided after dental school, and 24% knew before entering dental school that they wanted to be an orthodontist (Fig 3). When asked about their future plans after graduation, most residents indicated that they intended to practice orthodontics as an associate in the private sector (44%). Twenty-two percent stated that they intended to buy an existing orthodontic practice, and 13% planned to start a new orthodontic practice. Only 4% indicated that they intended to pursue a full-time research and teaching career (Table II). Most residents (66%) indicated that they planned to practice in an urban or suburban setting, and 9% planned to practice in an inner city. No residents were considering practicing in a rural location. A large majority of residents (82%) indicated that they planned to work in a private practice, whereas 9% said they would practice in a combination of community and academic settings. Only 5% said they would primarily work in an academic setting, and none was considering working primarily in a community setting. Forty-three percent said that they wanted to work in a group practice, with 30% in a solo practice and 27% undecided. All residents responded that they intended to be involved in direct patient care, as opposed to a purely research career. Most residents (84%) intend to practice full time (more than 3 days per week), and 9% intend to practice part-time (less than 3 days per week). Three of the 4 residents who said they would practice part-time were men. After graduation, most residents (95%) planned to stay in Canada. The most popular cities where they
646
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
Fig 1. Response to the question: what were the main factors influencing your decision to pursue an orthodontic residency training program? Residents could select all answers that applied.
Fig 2. Response to the question: what was the single most important factor influencing your decision to pursue an orthodontic residency training program?
wished to live and work were Montreal, Toronto, and Vancouver (Table III). When asked what percentage of time they would dedicate to either clinical or didactic research, 32% indicated no involvement, 32% were unsure, 30% planned to use 25% of their time, and 7% wanted to spend 50% or more of their time on research (Fig 4).
Regarding the treatment of patients with cleft lip and palate and craniofacial anomalies in their practice, 30% were considering doing so, and 14% were not; 48% said maybe, and 9% were unsure. A total of 80% were planning to use self-ligating brackets in their practice; 11% said maybe, 7% were unsure, and only 2% said they would not. When asked
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
Noble, Karaiskos, and Wiltshire
647
Fig 3. Response to the question: when did you decide to pursue an orthodontics training program?
whether they planned to use Invisalign (Align Technology, Santa Clara, Calif), 80% said they would, 16% said maybe, 5% were unsure, and none said that they would not. The respondents’ views concerning the importance of research in the program and the attainment of a master’s of science degree indicated that 55% were in favor, 23% said maybe, 14% were opposed, and 9% were unsure. When asked their opinion whether a shortened 24to 30-month orthodontic training program adequately prepares residents, 77% said no, and 23% said yes. DISCUSSION
There has never been a published survey of Canadian orthodontic residents. The limitation of this study is that it does not include residents who are training in the US or elsewhere and plan to move to Canada to practice orthodontics after graduation. The literature includes 2 surveys of residents from the US published over the past 13 years1,2 and a survey of residents in the UK.3 Keith and Proffit1 published a survey of orthodontic residents attending the Graduate Resident’s Orthodontic Conference and obtained responses from 168 residents, or 81% of those attending. Bruner et al2 conducted a similar study at the same meeting in 2003 in addition to mailing a survey; they obtained participation from 330 residents, for a response
rate of 77%; this represented 46% of US orthodontic residents. Keith et al3 also conducted a survey of orthodontic residents in the UK and obtained responses from 57 residents—a response rate of 64%. Our response rate of 81.48% was comparable with that of Keith and Proffit1 of 81% in the US and was higher than the other studies in the US and the UK. Keith and Proffit1 found that the most common reason for US residents to choose orthodontics as a career was expected future job satisfaction (89.7%). They also found that 13.7% chose orthodontics as a career because they were dissatisfied with general dentistry. Keith et al3 found that the most common reason for UK residents to choose orthodontics as a career was also expected job satisfaction (93%). Other reasons from that study included lifestyle (39%), good career structure (44%), no ‘‘on call’’ (33%), financial security (25%), dissatisfaction with general dentistry (21%), and an alternative to oral surgery (18%). We found that Canadian orthodontic residents decided to pursue a career in orthodontics because of intellectual stimulation, a passion for orthodontics, working with younger patients, workload flexibility and predictability, earning potential, and positive dental school experience in orthodontics. Intellectual stimulation and a passion for the specialty are probably closely related to an expectation for ‘‘future job satisfaction,’’ which would dovetail with the main reason that residents choose orthodontics
648
Noble, Karaiskos, and Wiltshire
Table II.
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
Future plans of orthodontic residents
Plan Practice orthodontics as an associate Practice orthodontics by buying into an existing practice Practice orthodontics by starting a new practice Apply for fellowship training in Canada Pursue a full-time research and teaching career Undecided
Percent 44.4 22.2 13.3 2.2 4.4 13.3
in Canada, the UK, and the US. Canadian residents also identified with UK residents with respect to career structure, workload flexibility and predictability, and earning potential of their future career. Although orthodontic practice might differ in the UK and North America, there nevertheless appears to be a common thread in residents’ perceptions in the 3 countries. The multiplechoice options offered to Canadian residents were different from those in the previous studies; this makes it difficult to compare the studies directly. In terms of future plans after graduation, Keith and Proffit1 found that 84% of residents intended to enter private practice, with about 50% planning to establish a solo practice or immediately buying in as a partner, and the other 50% expecting to enter an associateship type of practice. Unfortunately, only 6% of the respondents planned to teach. Bruner et al2 found similar results: 82% of the residents indicated that they intended to enter private practice after graduation, only 3% had plans for academia, and 4% considered either academia or something else. Interestingly, 40% reported that they would be interested in full-time academics if the salaries at universities improve. Orthodontic residents in the UK had similar responses, with only 7% indicating an interest in an academic career after graduation. Similar results were found among Canadian orthodontic residents, with 82% indicating that they intend to work in a private practice. Also, after graduation, 45% intended to become an associate in an existing practice, 13% planned to start their own practice, and 23% planned to buy an existing practice. Only 2 Canadian orthodontic residents said that they were interested in pursuing an academic career. This study further confirms the concerns of educators and professional organizations that the future of orthodontic education is in a crisis situation because of the lack of full-time orthodontic professors.4-12 The specialty of orthodontics in Canada, the US, and the UK is not immune to the concerns of the dental profession regarding the ability to recruit and retain residents who will eventually opt to become full-time, tenured academics. Most residents stated that they plan to practice in major cities, and none said that he or she planned to
Table III. Where Canadian orthodontic residents plan to practice when they graduate (n 5 44) City Montreal Canada (city not specified) Unsure Toronto Vancouver Outside Canada Calgary Ottawa Halifax Winnipeg Edmonton
Number 10 8 8 7 3 3 2 1 1 1 1
practice in a smaller city or a rural area. This might indicate a future need for orthodontists in these potentially underserviced areas. Most residents intend to work more than 3 days per week. No significant difference was found between sex and the decision to work full or part time. It might therefore be a generalized misconception that there are more part-time female orthodontists than their male counterparts. An interesting finding of our study was that an overwhelming number of residents indicated that they plan to use self-ligating brackets and Invisalign after graduation. This shows that graduate orthodontic programs are potentially fertile grounds for stimulating the acceptance of modern orthodontic technologies, and thus the future use of bracket systems and techniques by residents when they enter private practice, based on their experiences in the graduate program. Thirty percent of the residents said they plan to care for patients with cleft lip and palate and craniofacial anomalies in their practice. This shows altruism from some graduating orthodontic residents, despite the potentially difficult, long-lasting care and often minimal financial benefit of treating these patients. However, the 70% of residents not planning to treat these patients might be reluctant because of a lack of exposure to these patients during their residency and not necessarily from a lack of altruism. Only 1 Canadian resident indicated an interest in pursuing fellowship training in either Canada or the US; the assumption was that the fellowship program would be in the treatment of patients with cleft lip and palate or craniofacial syndromes. Because most craniofacial deformities are either faculty- or hospital-based, it is a looming problem that, with retiring full-time faculty with expertise in this area, the future availability of services could be at risk.
Noble, Karaiskos, and Wiltshire
American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 5
649
Fig 4. Amount of time (%) residents plan to dedicate to didactic or clinical research (n 5 44).
Most residents believe that an orthodontic training program should have a research-based master’s of science component. An overwhelming number of respondents thought that a shorter orthodontic residency training program of only 24 to 30 months is not adequate preparation. However, all Canadian orthodontic training programs are at least 35 or 36 months long, and bias is possible in their perception. An extended 35- or 36-month program with a research component, when offered in American and Canadian accredited programs, is supported because of the increased capacity for critical analysis and the objective evaluation of new scientific technological advancements.13 Furthermore, a 3-year program would provide for more clinical, didactic, and research time and raise clinical understanding and standards, because students see more patients and be expected to start and finish them, as well as follow them through several months of retention. However, even though residents favor a longer orthodontic program combined with a research component, they nevertheless failed to indicate that they were more interested in an academic career than orthodontic residents in the US, where there are shorter 24- to 30-month programs. This might indicate that a longer program combined with a research component does not guarantee, as one might expect, that more orthodontic residents will be produced with a higher affinity for research and are thus more motivated to pursue an
academic career. Selection committees for graduate orthodontic programs might need to rethink their selection strategies if they need to train clinical orthodontists with a research-based degree who are targeted to eventually fill the academic void and assist in alleviating the current crisis in orthodontic recruitment and retention. CONCLUSIONS
1.
2.
3.
4.
5.
The appeal of intellectual stimulation is the most common motivating factor for Canadian dental students who choose to specialize in orthodontics. Most Canadian orthodontic residents will use modern techniques such as self-ligating brackets and Invisalign after graduation. Canadian orthodontic programs might find an exacerbation of the shortage of clinically based orthodontic researchers and full-time academics in the future and should consider measures to prevent this. Most orthodontic residents intend to enter urban or suburban private practices after graduation, and rural areas are at an increasing risk of being underserviced. Canadian orthodontic residents believe that 24- to 30-month orthodontic residency programs do not adequately prepare them for an orthodontic career and favor longer 35- to 36-month programs with a research-based or master’s of science component.
650
Noble, Karaiskos, and Wiltshire
REFERENCES 1. Keith O, Proffit WR. Orthodontic training: the residents’ perspective. Am J Orthod Dentofacial Orthop 1994;106:649-53. 2. Bruner MK, Hilgers KK, Silveira AM, Butters JM. Graduate orthodontic education: the residents’ perspective. Am J Orthod Dentofacial Orthop 2005;128:277-82. 3. Keith O, Stevens CD, Proffit WR, O’Brien KD. A survey of the opinions of orthodontic specialist trainees in the U.K. Br J Orthod 1997;24:163-7. 4. Meskin LH. Those who can, do. J Am Dent Assoc 2000;13: 428-32. 5. Livingston HM, Dellinger TM, Hyde JC, Holder R. The aging and diminishing dental faculty. J Dent Educ 2004;68:345-54. 6. Nunn PJ, Gadbury-Amyot CC, Battrell A, Bruce SI, Hanlon LL, Kaiser C, et al. The current status of allied dental faculty: a survey report. J Dent Educ 2004;68:329-44.
American Journal of Orthodontics and Dentofacial Orthopedics November 2009
7. Flores-Mir C. Dental faculty shortage in the United States and Canada: are there solutions? J Can Dent Assoc 2007;72:725-6. 8. Noble J. Dental faculty shortage. J Can Dent Assoc 2007;72: 870. 9. Lindauer SJ, Peck SL, Tufekci E, Coffey T, Best AM. The crisis in orthodontic education: goals and perceptions. Am J Orthod Dentofacial Orthop 2003;124:480-7. 10. Larson B. Faculty recruitment and retention: challenge or crisis. Am J Orthod Dentofacial Orthop 1998;113:122-3. 11. Haden ND, Beemsterboer RG, Weaver RG, Valachovic RW. Dental school faculty shortages increase: an update on future dental school faculty. J Dent Educ 2000;64:657-73. 12. Trotman CA, Bennett E, Scheffler N, Tulloch JC. Faculty recruitment, retention, and success in dental academia. Am J Orthod Dentofacial Orthop 2002;122:2-8. 13. Sinclair PM, Alexander RG. Orthodontic graduate education survey. Am J Orthod 1984;85:175-81.