- Email: [email protected]
Rural dentists
TRENDS
Rural dentists Does growing up in a small community matter? Kimberly K. McFarland, DDS, MHSA; John W. Reinhardt, DDS, MS, MPH; Muhammad Yaseen, MS
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✷ Background. The aging of the dental work force has implications for both patients and dentists, especially those in rural and underserved areas. Anecdotal information regarding dental A 4 workforce trends indicates that students from rural R T I C L E communities are more likely to practice in rural communities than are students from urban areas. Although the medical literature supports this premise relative to physicians, there are no data to verify this statement relative to dentistry. Therefore, the authors decided to study whether this premise applies to dentistry. Methods. The authors conducted a retrospective analysis of dental student records from a Midwestern dental school for the years 1980 through 2010 to determine if there was a statistical correlation between the size of a dental student’s town of origin and the size of the community where he or she practiced after graduation. They also examined what role, if any, the student’s sex played. Results. Dentists from rural areas were approximately six times more likely to practice in a rural area than were dentists from urban areas. Female dentists were only slightly less likely to practice in a rural community than were male dentists. Conclusion. Dentists from rural communities were more likely to practice in rural communities than were dental students from urban areas. Practice Implications. To ensure future access to care in rural communities, rural dentists may want to recruit actively or work closely with dental students from rural areas when hiring associates or seeking purchasers for their dental practices. Key Words. Dentists; rural health; women dentists; private practice; retirement; students. JADA 2012;143(9):1013-1019. IO N
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he “graying” of America is occurring in many professions, including dentistry. The median age of dentists practicing in the United States is approximately 50 years.1 The results of workforce studies have indicated that for every one dentist who graduates from dental school, two dentists will retire.1-5 According to dental education reports, approximately 5,000 dentists graduate from dental school annually.6,7 These demographic changes may have a significant impact on retiring dentists, especially those practicing in rural or underserved areas, and the patients they serve. The U.S. Census Bureau defines rural areas as all territories outside of Census Bureau–defined urban areas and urban clusters.8 An urban area consists of a central city and surrounding areas in which population is greater than 50,000 people. Although most states have urban centers, many also have rural areas in which the population is 50,000 or fewer people.7 Approximately 20 percent of the U.S. population lives in rural areas, whereas only 14 percent of dentists practice in rural locations.8,9 Of
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Dr. McFarland is an associate professor, Department of Oral Biology, College of Dentistry, University of Nebraska Medical Center, 40th & Holdrege St., Lincoln, Neb. 68583, e-mail [email protected]. Address reprint requests to Dr. McFarland. Dr. Reinhardt is the dean and a professor, Department of Adult Restorative Dentistry, College of Dentistry, University of Nebraska Medical Center, Lincoln. Mr. Yaseen is a graduate student, Department of Statistics, College of Arts and Sciences, University of Nebraska at Lincoln.
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these dentists, 8 percent practice in large rural areas, 4 percent in small rural areas and 2 percent in isolated rural areas.10 Of the 2,050 rural counties in the United States, 1,221 (60 percent) are designated as dental Health Professional Shortage Areas (HPSAs).11 Approximately 47 million people live in federally designated dental HPSAs.12 Considering the aging dental workforce and projections that large numbers of dentists plan to retire, states with significant rural populations have reason to be concerned.2,13 To address these concerns, several dental schools have opened recently.7 The new schools’ effect on access to care in rural communities, however, is unknown. In Nebraska, Wyoming, South Dakota and Kansas, the effects of rural dentists’ retiring may be especially significant. In 2007 in Nebraska, there were approximately 63 dentists per 100,000 people.14 The more telling data, however, are that in 2007 in Nebraska, approximately 5 percent of the practicing dentists were 70 years or older and 17 percent were 60 to 69 years.15 In 2007 in Nebraska, 20 of the 93 counties had no dentists and 22 counties had only one or two dentists. In 2007 in Wyoming, there were approximately 48 dentists per 100,000 people,16 and 16 percent of the dentists were 65 years or older.17 In 2007 in South Dakota18 and Kansas,19 there were approximately 50 and 52 dentists per 100,000 people, respectively, and 25 and 20 percent of the dentists were 60 years or older, respectively.20,21 The aging of dentists in rural communities may have significant consequences unless efforts are made to replace these retiring dentists with new dentists. To address these concerns, various approaches to encourage dental students to practice in rural and underserved areas have been used. They include, but are not limited to, recruitment of rural applicants, rural health education rotations and student loan repayment programs for dentists who practice in rural and underserved areas.22-24 Although schools have found these approaches to be helpful, the real significance of recruiting dental students from rural communities has not been studied. The medical literature indicates that medical students who come from rural areas are more likely to practice in rural communities.25-27 No studies exist regarding dental students. However, anecdotal information from senior faculty members at the College of Dentistry (COD) at the University of Nebraska Medical Center (UNMC) who have served on the admissions committee indicated that students who graduated from rural high schools were more likely to 1014 JADA 143(9)
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practice in a rural community. The COD is a public dental school that accepts students from all 50 states and all U.S. territories and has been educating dentists since 1899 (Curtis G. Kuster, DDS, MS, admissions director, College of Dentistry, University of Nebraska Medical Center, oral communication, May 25, 2011). Approximately 40 percent of the students accepted at the COD are from states other than Nebraska. The COD promotes programs specifically designed to attract rural applicants. UNMC has incorporated summer medical and dental student enrichment programs, state college programs with guaranteed admission to doctoral programs, and rural education requirements into the curriculum. Generally, 800 to 1,000 students apply annually for the 45 dental student positions at the COD, and approximately 50 percent of the applicants to the COD are from rural communities (Merlyn Vogt, DDS, admissions director, College of Dentistry, University of Nebraska Medical Center, oral communication, March 12, 2012). Eighty-seven percent of the dentists in rural Nebraska are graduates of the COD.15 Historically, COD graduates have practiced primarily in Nebraska, South Dakota, North Dakota, Wyoming and Kansas. However, COD graduates currently practice in 49 states. The results of dental workforce studies have indicated that male dentists are more likely than are female dentists to practice in rural communities.28,29 Similarly, the results of medical studies indicated that male physicians are more likely to practice in rural communities than are female physicians.30-32 The ratio of male to female physicians practicing in rural areas is 7.6:1.0.31 Although female dentists and physicians are a small percentage of the workforce, their numbers are increasing. In 1982, female dentists were 3 percent of the workforce.33 In 2009, female dentists were 20 percent of the dental workforce.1 We conducted a study to test the hypothesis that dental students from small communities are more likely than students from urban areas to practice in small communities. If the hypothesis is valid, how significant is the size of a community from which a dental student comes in determining where he or she practices? In addition, what role, if any, does the student’s sex play in determining whether he or she practices in rural communities?
ABBREVIATION KEY. COD: College of Dentistry. HPSA: Health Professional Shortage Area. UNMC: University of Nebraska Medical Center.
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TRENDS
METHODS
We conducted a retrospective analysis of predoctoral dental student records (n = 1,361) for the years 1980 through 2010. We included only the records of students who successfully completed the dental education program. We excluded from the analysis foreign-trained or advanced-standing students from countries other than the United States. The Figure 1. Dentists’ states of origin. institutional review board at UNMC TABLE 1 approved the Distribution of graduates from the College of research. We assessed the Dentistry at the University of Nebraska Medical year the dentist gradCenter, according to decade of graduation and sex. uated; the dentist’s DECADE OF WOMEN, NO., % MEN, NO., % TOTAL, NO., % sex; the city, county GRADUATION and state in which 1980-1990 79 (14) 473 (86) 552 (100) the dentist attended 1991-2000 110 (28) 282 (72) 392 (100) high school; and the dentist’s current 2001-2010 155 (37) 262 (63) 417 (100) address, including TOTAL 344 (25) 1,017 (75) 1,361 (100) the city, county and Besides Nebraska, most graduates came from state in which he or she practiced. We used Wyoming, Kansas, South Dakota and Utah. decade-specific U.S. Census Bureau data to Most graduates practiced in Nebraska, Coldetermine the population sizes of the counties in orado, South Dakota and Kansas. which the dentists practiced. For the decades of 1980-1990, 1991-2000 and We performed quantitative and qualitative 2001-2010, there were 552, 392 and 417 UNMC statistical analysis by using statistical software. COD graduates, respectively. Table 1 shows the We conducted abivariate analysis to identify the number of graduates, according to decade and relationships between the graduates’ counties of sex. During this 31-year period, 25 percent of origin and the counties in which they practiced, the graduates were women. From 1980-1990, according to their graduation decade. We used 14 percent (79 of 552) of the graduates were cross-tabulations to determine the distribution of women. In the decade from 2001 through 2010, graduates, according to decade and sex. We con37 percent (155 of 417) of the graduates were ducted odds ratio analyses to characterize and women. quantify the relationships between the county in Fifty-two percent of the graduates came from which the dentist practiced based on its size and counties with populations of 50,000 or fewer. the size of the dentist’s county of origin. Approximately 26 percent of the graduates were RESULTS from counties with populations of 50,001 to Dental students from 38 states were repre250,000, and 21 percent were from counties sented in the 1980-2010 UNMC dental student with populations greater than 250,000. records. Approximately 44 percent of all dental Figure 2 shows the distribution of dentists students at UNMC during this period were not practicing in various-sized counties, according from Nebraska. to decade of graduation. Thirty-three percent of Figure 1 shows the dentists’ states of origin. the dentists who graduated in the 1980-1990 JADA 143(9)
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GRADUATES PRACTICING IN COUNTIES OF VARIOUS SIZES (%)
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1991-2000
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Figure 2. Distribution of College of Dentistry at the University of Nebraska Medical Center graduates practicing in counties of various sizes, according to decade of graduation.
GRADUATES PRACTICING IN COUNTIES OF VARIOUS SIZES (%)
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Likewise, 53 percent of graduates from counties with populations of 50,001 to 250,000 and 60 percent of graduates from counties with populations greater than 250,000 practiced in similarly sized communities. In general, dentists practiced in communities that were the same size as those in which they were raised. The results of the odds ratio analyses indicated that graduates who came from a county with a population of 50,000 or fewer were 5.2 times more likely (95 percent confidence interval [CI], 4.0-6.7) to practice in a county with a population of 50,000 or fewer than were their colleagues who came from more urban areas (Table 2). Likewise, graduates from a county with a population of 25,000 or fewer were 5.1 times more likely (95 percent CI, 3.9-6.8) to practice in a county with a population of 25,000 or fewer. For graduates from a town with a population of 10,000 or fewer, the odds were even greater at 5.7 (95 percent CI, 3.8-8.8). Male dentists were 1.4 times (95 percent CI, 1.0-1.8) more likely to practice in a county with a population of 50,000 or fewer compared with female dentists. Findings were similar for smaller counties. Male dentists were 1.3 times (95 percent CI, 0.9-1.8) more likely to practice in a county with a population of 25,000 or fewer and they were 1.2 times (95 percent CI, 0.7-12.0) more likely to practice in a county with a population of 10,000 or fewer than were female dentists.
COUNTY OF ORIGIN SIZE
DISCUSSION Figure 3. Distribution of College of Dentistry at the University of Nebraska Medical Center graduates from 1980-2010, according to size of county of origin and county in which they practiced.
and 2001-2010 decades practiced in counties with populations of 50,000 or fewer. Thirty-eight percent of the 1991-2000 graduates practiced in counties with populations of 50,000 or fewer. Overall, the study’s results show that approximately 35 percent of the 1980-2010 graduates practiced in counties with populations of 50,000 or fewer. The percentage of dentists who came from and practiced in various-sized counties is shown in Figure 3. Fifty-one percent of the graduates from counties with populations of 50,000 or fewer practiced in counties of the same size. 1016
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Although the results of a number of studies in the medical literature have shown that physicians who grow up in small towns tend to practice in small towns,25-27 no such workforce studies relative to dentistry have been conducted. The results of our study of 31 years of students’ records from UNMC COD suggest trends in regard to practice location. Dentists who were from rural communities (counties with a population of 50,000 or fewer) were more likely to practice in rural communities than were their colleagues who were from urban areas (counties with populations greater than 50,000). Dentists tend to practice in communities of the same size as those in which they were raised. Dentists from counties with populations
September 2012
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TRENDS TABLE 2 of 10,000 or fewer were almost six times Odds ratios for graduates from the College of more likely than were Dentistry at the University of Nebraska Medical dentists from urban areas to return to a Center who practiced in a county that was the same similar-sized commusize as their county of origin. nity, and dentists COUNTY POPULATION ODDS RATIO 95% CONFIDENCE INTERVAL from counties with populations of 50,000 ≤ 50,000 5.2 4.0-6.7 or fewer were approxi- ≤ 25,000 5.1 3.9-6.8 mately five times ≤ 10,000 5.7 3.8-8.8 more likely than were dentists from urban areas to return to a similar-sized community. nities and challenges of rural practice. In addiFemale dentists were only slightly less likely tion, teledentistry consultations with COD speto practice in a rural county than were their cialists from rural sites, as well as state student male colleagues. As the county population beloan and loan repayment programs, have concame smaller, the odds of female dentists practributed to attracting dental school graduates to ticing in such counties were greater. This practice in rural areas (Curtis Kuster, DDS, MS, finding calls into question the conventional admissions director, University of Nebraska wisdom that male dentists are more likely to Medical Center, College of Dentistry, oral compractice in rural communities. In the early munication, April 4, 2011). Approximately one to 1980s, fewer than 3 percent of the dentists in two dental students in each graduating class the United States were women. Currently, participate annually in the state student loan female dentists may be graduating in sufficient program (Merlyn Vogt, DDS, admissions numbers to draw meaningful conclusions director, College of Dentistry, University of regarding their practice patterns. Also, these Nebraska Medical Center, oral communication, practice patterns are in stark contrast with March 12, 2012). Although we did not consider the challenges of recruiting rural applicants, those of female physicians, who according to the student recruitment, the loan repayment promedical literature are significantly more likely to practice in urban areas.30-32 These practice gram and other rural recruitment incentives patterns warrant further research, especially as warrant additional research. the number of female dentists continues to Our study was not a longitudinal study, but increase. rather a study at one point in time. We classified The limitations of this study are that these recent graduates enrolled in advanced education findings are only from one Midwestern dental programs or those with military obligations acschool—UNMC COD. Other dental schools may cording to the size of the community in which have different data. The UNMC COD is a public they were working. Approximately one-third of school, which may have influenced the type of all UNMC COD graduates continued their eduapplicants who were admitted to the program, cation by means of an advanced-degree program as well as the student loan debt burden dentists or had a military obligation (Merlyn Vogt, DDS, have when they graduate. Future studies admissions director, College of Dentistry, Uniinvolving the same retrospective data analysis versity of Nebraska Medical Center, oral comin an urban dental school (public or private) munication, March 12, 2012). Therefore, the may address the limitations of our study. findings for the 2000-2010 period are likely more The UNMC COD has instituted programs to significant than what we reported, as graduates actively recruit applicants from rural communifrom those years generally practice in urban setties for more than two decades. These programs tings for two to three years until they relocate to have included, but are not limited to, summer and practice in a community of their choice. enrichment programs, state college programs Although we have worked with rural dentists for students with minimum grade point average for many years and received requests for assistrequirements for guaranteed admission to denance in identifying students or recent graduates tal school, and targeted recruitment of students who would be a “good fit” for a specific commufrom rural schools. These programs have comnity, we did not address dental care provider plemented the dental school curriculum that recruitment or retention efforts in our study. In requires rural externships. These externships some instances a rural dentist may be the only allow dental students to experience the opportudentist in the county and therefore may view JADA 143(9)
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the sale of his or her practice as not only a business transaction but a continuing legacy of service to the community. These topics may warrant future research to determine why dentists practice and live in rural communities, as well as what criteria rural dentists consider important when selling their practices. This study’s results were limited to one Midwestern dental school, but they support the following general findings: drural dentists should consider recruiting or selling their practices to dentists from rural areas; dsuch dentists can be either male or female, which is in contrast to medicine, in which male physicians are more likely to practice in rural areas than are female physicians; ddental schools may need to admit more dental students from rural areas to address the shortage of dentists in rural areas. The results of this study indicate that a Midwestern dental school can have a significant influence on regional workforce needs. Although students from 38 states were admitted, they went on to practice in 44 states. Most practiced in Nebraska or other states in the region. Rural dentists who want to sell their practices should consider dentists from all dental schools within a multistate region as prospective purchasers of their practices. Likewise, dental school administrators may want to consider accepting qualified applicants from rural areas, regardless of whether they are in-state or out-of-state applicants. CONCLUSIONS
The results of our analyses suggest that the size of the community from which a dental student originates is a significant factor in determining where he or she practices. In general, dentists tend to practice in the same-sized community as that in which they were raised. Male dentists were only slightly more likely to practice in a rural community than were female dentists. Dentists who are considering hiring an associate or selling their practices may want to consider the size of the community in which the prospective associate or colleague was raised, in addition to actively recruiting and encouraging local young people to consider dentistry as a career. Likewise, the administrators of dental schools, depending on their university’s mission and regional workforce needs, may want to focus more or less attention on dental student applicants who come from rural areas. ■ Disclosure. None of the authors reported any disclosures.
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The authors thank Mr. Kim Theesen for formatting the graphics included in the manuscript and Mrs. Debra Rodaway for her assistance with data collection and entry. 1. American Dental Association (ADA) Survey Center. Distribution of Dentists in the United States by Region and State, 2009. Chicago: American Dental Association; 2010:26. 2. Beazoglou T, Bailit H, Brown LJ. Selling your practice at retirement: are there problems ahead? JADA 2000;131(12):1693-1698. 3. Brown JB, Lazar V. Dentist work force and educational pipeline. JADA 1998;129:1700-1707. 4. U.S. Department of Health and Human Services, Bureau of Health Professions. Seventh Report to the President and Congress on the State of Health Personnel in the United States. Washington: U.S. Department of Health and Human Services; 1991. 5. American Association of Dental Schools. Deans briefing book: Academic year,1991-1992. Washington: American Association of Dental Schools; 1992. 6. American Dental Association Survey Center. Academic Programs, Enrollment, and Graduates. Chicago: American Dental Association; 2011:45. 2009-2010 Survey of Dental Education; vol. 1. 7. Guthrie D, Valachovic RW, Brown LJ. The impact of new dental schools on the dental workforce through 2022. J Dent Educ 2009; 73:1353-1360. 8. Urban and rural definitions, released Oct. 1995. U.S. Census Bureau. www.census.gov/population/censusdata/urdef.txt. Accessed July 3, 2012. 9. U.S. Department of Health and Human Services, Health Resources and Services Administration, The Office of Rural Health Policy. Office of Rural Health Policy Rural Guide to Federal Health Professions Funding. Rockville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy; 2011:2. 10. National Rural Health Association. Recruitment and Retention of a Quality Health Workforce in Rural Areas: A series of Policy Papers on the Rural Health Careers Pipeline, Number 4—Oral Health (issue paper). November 2006. Kansas City, Mo.: National Rural Health Association; 2006:1-3. 11. U.S. Institute of Medicine, Committee on the Future of Rural Health Care. Quality Through Collaboration: The Future of Rural Health. Washington: National Academies Press; 2004:1-2. 12. U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Professions. Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. http://bhpr.hrsa.gov/shortage. Accessed July 12, 2012. 13. Kuthy RA, McKernan SC, Hand JS, Johnsen DC. Dentist workforce trends in a primarily rural state: Iowa—1997-2007. JADA 2009; 40(12):1527-1534. 14. The Henry J. Kaiser Family Foundation. State Health Facts.org: Nebraska—dentists. www.statehealthfacts.org/profileind.jsp? cmprgn=7&cat=8&rgn=29&sub=104. Accessed July 31, 2012. 15. Mueller K, Nayar P, Shaw-Sutherland K, et al. “A Critical Match”: Nebraska’s Health Workforce Planning Project Final Report. Omaha, Neb.: Nebraska Center for Rural Health Research, University of Nebraska Medical Center College of Public Health; 2009. www.unmc.edu/rural/documents/NebraskaWorkforceProjectFinal 091509.pdf. Accessed July 5, 2012. 16. The Henry J. Kaiser Family Foundation. State Health Facts.org: Wyoming—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?cmprgn=29&cat=8&rgn=52 &ind=966&sub=104. Accessed July 31, 2012. 17. University of Washington Center for Health Workforce Studies. Data Snapshot: Wyoming Dentists, 2009. http://depts.washington.edu/ uwrhrc/uploads/WY_Dentists_DS.pdf. Accessed July 5, 2012. 18. The Henry J. Kaiser Family Foundation. State Health Facts.org: South Dakota—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?ind=966&cat=8&rgn=43. Accessed July 31, 2012. 19. The Henry J. Kaiser Family Foundation. State Health Facts.org: Kansas—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?ind=966&cat=8&rgn=18. Accessed Aug. 2, 2012. 20. South Dakota Department of Health. 2011 Healthcare Workforce Report. http://doh.sd.gov/RuralHealth/Workforce/ 2011WorkforceReport.pdf. Accessed July 5, 2012. 21. Kansas Department of Health and Environment, Bureau of Oral Health. Kansas 2009 Oral Health Workforce Assessment.
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www.kdheks.gov/ohi/download/2009_Oral_Health_Workforce_ Assessment.pdf. Accessed July 5, 2012. 22. Haden NK, Catalanotto FA, Alexander CJ, et al. Improving the oral health status of all Americans: roles and responsibilities of academic dental institutions: the report of the ADEA President’s Commission. J Dent Ed 2003;67(5):563-583. 23. Davidson PL, Carreon DC, Baumeister SE, et al. Influence of contextual environment and community-based dental education on practice plans of graduating seniors. J Dent Edu 2007;71(3):403-418. 24. Formicola A, Bailit H, D’Abreu K, et al. The Dental Pipeline program’s impact on access disparities and student diversity. JADA 2009;140(3):346-353. 25. Seifer SD, Vranizan K, Grumbach K. Graduate medical education and physician practice location: implications for physician workforce policy. JAMA 1995;274(9):685-691. 26. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase rural physician supply: a systematic review and projected impact of widespread replication. Acad Med 2008;83(3):235-243.
27. Pepper CM, Sandefer RH, Gray MJ. Recruiting and retaining physicians in very rural areas. J Rural Health 2010;26(2):196-200. 28. Wall TP, Brown LJ. The urban and rural distribution of dentists, 2000. JADA 2007;138(7):1003-1011. 29. American Dental Association. Dental Workforce Model Report: Distribution of Dentists in the United States by Region and State. Chicago: American Dental Association; 2006. 30. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ. Increasing the supply of women physicians in rural areas: outcomes of a medical school rural program. J Am Board Fam Med 2011;24(6): 740-744. 31. Spenny ML, Ellsbury KF. Perceptions of practice among rural family physicians: is there a gender difference? J Am Board Fam Pract 2000;13(3):183-187. 32. Glasser M, Hunsaker M, Sweet K, MacDowell M, Meurer M. A comprehensive medical education program response to rural primary care needs. Acad Med 2008;83(10):952-961. 33. Brown LJ. Dental work force strategies during a period of change and uncertainty. J Dent Educ 2001;65(12):1404-1416.
JADA 143(9)
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Copyright © 2012 American Dental Association. All rights reserved.
September 2012 1019
Rural dentists Does growing up in a small community matter? Kimberly K. McFarland, DDS, MHSA; John W. Reinhardt, DDS, MS, MPH; Muhammad Yaseen, MS
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✷ Background. The aging of the dental work force has implications for both patients and dentists, especially those in rural and underserved areas. Anecdotal information regarding dental A 4 workforce trends indicates that students from rural R T I C L E communities are more likely to practice in rural communities than are students from urban areas. Although the medical literature supports this premise relative to physicians, there are no data to verify this statement relative to dentistry. Therefore, the authors decided to study whether this premise applies to dentistry. Methods. The authors conducted a retrospective analysis of dental student records from a Midwestern dental school for the years 1980 through 2010 to determine if there was a statistical correlation between the size of a dental student’s town of origin and the size of the community where he or she practiced after graduation. They also examined what role, if any, the student’s sex played. Results. Dentists from rural areas were approximately six times more likely to practice in a rural area than were dentists from urban areas. Female dentists were only slightly less likely to practice in a rural community than were male dentists. Conclusion. Dentists from rural communities were more likely to practice in rural communities than were dental students from urban areas. Practice Implications. To ensure future access to care in rural communities, rural dentists may want to recruit actively or work closely with dental students from rural areas when hiring associates or seeking purchasers for their dental practices. Key Words. Dentists; rural health; women dentists; private practice; retirement; students. JADA 2012;143(9):1013-1019. IO N
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he “graying” of America is occurring in many professions, including dentistry. The median age of dentists practicing in the United States is approximately 50 years.1 The results of workforce studies have indicated that for every one dentist who graduates from dental school, two dentists will retire.1-5 According to dental education reports, approximately 5,000 dentists graduate from dental school annually.6,7 These demographic changes may have a significant impact on retiring dentists, especially those practicing in rural or underserved areas, and the patients they serve. The U.S. Census Bureau defines rural areas as all territories outside of Census Bureau–defined urban areas and urban clusters.8 An urban area consists of a central city and surrounding areas in which population is greater than 50,000 people. Although most states have urban centers, many also have rural areas in which the population is 50,000 or fewer people.7 Approximately 20 percent of the U.S. population lives in rural areas, whereas only 14 percent of dentists practice in rural locations.8,9 Of
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Dr. McFarland is an associate professor, Department of Oral Biology, College of Dentistry, University of Nebraska Medical Center, 40th & Holdrege St., Lincoln, Neb. 68583, e-mail [email protected]. Address reprint requests to Dr. McFarland. Dr. Reinhardt is the dean and a professor, Department of Adult Restorative Dentistry, College of Dentistry, University of Nebraska Medical Center, Lincoln. Mr. Yaseen is a graduate student, Department of Statistics, College of Arts and Sciences, University of Nebraska at Lincoln.
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September 2012 1013
TRENDS
these dentists, 8 percent practice in large rural areas, 4 percent in small rural areas and 2 percent in isolated rural areas.10 Of the 2,050 rural counties in the United States, 1,221 (60 percent) are designated as dental Health Professional Shortage Areas (HPSAs).11 Approximately 47 million people live in federally designated dental HPSAs.12 Considering the aging dental workforce and projections that large numbers of dentists plan to retire, states with significant rural populations have reason to be concerned.2,13 To address these concerns, several dental schools have opened recently.7 The new schools’ effect on access to care in rural communities, however, is unknown. In Nebraska, Wyoming, South Dakota and Kansas, the effects of rural dentists’ retiring may be especially significant. In 2007 in Nebraska, there were approximately 63 dentists per 100,000 people.14 The more telling data, however, are that in 2007 in Nebraska, approximately 5 percent of the practicing dentists were 70 years or older and 17 percent were 60 to 69 years.15 In 2007 in Nebraska, 20 of the 93 counties had no dentists and 22 counties had only one or two dentists. In 2007 in Wyoming, there were approximately 48 dentists per 100,000 people,16 and 16 percent of the dentists were 65 years or older.17 In 2007 in South Dakota18 and Kansas,19 there were approximately 50 and 52 dentists per 100,000 people, respectively, and 25 and 20 percent of the dentists were 60 years or older, respectively.20,21 The aging of dentists in rural communities may have significant consequences unless efforts are made to replace these retiring dentists with new dentists. To address these concerns, various approaches to encourage dental students to practice in rural and underserved areas have been used. They include, but are not limited to, recruitment of rural applicants, rural health education rotations and student loan repayment programs for dentists who practice in rural and underserved areas.22-24 Although schools have found these approaches to be helpful, the real significance of recruiting dental students from rural communities has not been studied. The medical literature indicates that medical students who come from rural areas are more likely to practice in rural communities.25-27 No studies exist regarding dental students. However, anecdotal information from senior faculty members at the College of Dentistry (COD) at the University of Nebraska Medical Center (UNMC) who have served on the admissions committee indicated that students who graduated from rural high schools were more likely to 1014 JADA 143(9)
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practice in a rural community. The COD is a public dental school that accepts students from all 50 states and all U.S. territories and has been educating dentists since 1899 (Curtis G. Kuster, DDS, MS, admissions director, College of Dentistry, University of Nebraska Medical Center, oral communication, May 25, 2011). Approximately 40 percent of the students accepted at the COD are from states other than Nebraska. The COD promotes programs specifically designed to attract rural applicants. UNMC has incorporated summer medical and dental student enrichment programs, state college programs with guaranteed admission to doctoral programs, and rural education requirements into the curriculum. Generally, 800 to 1,000 students apply annually for the 45 dental student positions at the COD, and approximately 50 percent of the applicants to the COD are from rural communities (Merlyn Vogt, DDS, admissions director, College of Dentistry, University of Nebraska Medical Center, oral communication, March 12, 2012). Eighty-seven percent of the dentists in rural Nebraska are graduates of the COD.15 Historically, COD graduates have practiced primarily in Nebraska, South Dakota, North Dakota, Wyoming and Kansas. However, COD graduates currently practice in 49 states. The results of dental workforce studies have indicated that male dentists are more likely than are female dentists to practice in rural communities.28,29 Similarly, the results of medical studies indicated that male physicians are more likely to practice in rural communities than are female physicians.30-32 The ratio of male to female physicians practicing in rural areas is 7.6:1.0.31 Although female dentists and physicians are a small percentage of the workforce, their numbers are increasing. In 1982, female dentists were 3 percent of the workforce.33 In 2009, female dentists were 20 percent of the dental workforce.1 We conducted a study to test the hypothesis that dental students from small communities are more likely than students from urban areas to practice in small communities. If the hypothesis is valid, how significant is the size of a community from which a dental student comes in determining where he or she practices? In addition, what role, if any, does the student’s sex play in determining whether he or she practices in rural communities?
ABBREVIATION KEY. COD: College of Dentistry. HPSA: Health Professional Shortage Area. UNMC: University of Nebraska Medical Center.
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TRENDS
METHODS
We conducted a retrospective analysis of predoctoral dental student records (n = 1,361) for the years 1980 through 2010. We included only the records of students who successfully completed the dental education program. We excluded from the analysis foreign-trained or advanced-standing students from countries other than the United States. The Figure 1. Dentists’ states of origin. institutional review board at UNMC TABLE 1 approved the Distribution of graduates from the College of research. We assessed the Dentistry at the University of Nebraska Medical year the dentist gradCenter, according to decade of graduation and sex. uated; the dentist’s DECADE OF WOMEN, NO., % MEN, NO., % TOTAL, NO., % sex; the city, county GRADUATION and state in which 1980-1990 79 (14) 473 (86) 552 (100) the dentist attended 1991-2000 110 (28) 282 (72) 392 (100) high school; and the dentist’s current 2001-2010 155 (37) 262 (63) 417 (100) address, including TOTAL 344 (25) 1,017 (75) 1,361 (100) the city, county and Besides Nebraska, most graduates came from state in which he or she practiced. We used Wyoming, Kansas, South Dakota and Utah. decade-specific U.S. Census Bureau data to Most graduates practiced in Nebraska, Coldetermine the population sizes of the counties in orado, South Dakota and Kansas. which the dentists practiced. For the decades of 1980-1990, 1991-2000 and We performed quantitative and qualitative 2001-2010, there were 552, 392 and 417 UNMC statistical analysis by using statistical software. COD graduates, respectively. Table 1 shows the We conducted abivariate analysis to identify the number of graduates, according to decade and relationships between the graduates’ counties of sex. During this 31-year period, 25 percent of origin and the counties in which they practiced, the graduates were women. From 1980-1990, according to their graduation decade. We used 14 percent (79 of 552) of the graduates were cross-tabulations to determine the distribution of women. In the decade from 2001 through 2010, graduates, according to decade and sex. We con37 percent (155 of 417) of the graduates were ducted odds ratio analyses to characterize and women. quantify the relationships between the county in Fifty-two percent of the graduates came from which the dentist practiced based on its size and counties with populations of 50,000 or fewer. the size of the dentist’s county of origin. Approximately 26 percent of the graduates were RESULTS from counties with populations of 50,001 to Dental students from 38 states were repre250,000, and 21 percent were from counties sented in the 1980-2010 UNMC dental student with populations greater than 250,000. records. Approximately 44 percent of all dental Figure 2 shows the distribution of dentists students at UNMC during this period were not practicing in various-sized counties, according from Nebraska. to decade of graduation. Thirty-three percent of Figure 1 shows the dentists’ states of origin. the dentists who graduated in the 1980-1990 JADA 143(9)
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TRENDS
GRADUATES PRACTICING IN COUNTIES OF VARIOUS SIZES (%)
100
80
26
30
44
60
36
37
Practice County Population
23
40
< 50,000 50,001-250,000 > 250,000
20
38
33
33
0 1980-1990
1991-2000
2001-2010
GRADUATION DECADE
Figure 2. Distribution of College of Dentistry at the University of Nebraska Medical Center graduates practicing in counties of various sizes, according to decade of graduation.
GRADUATES PRACTICING IN COUNTIES OF VARIOUS SIZES (%)
100
23
31
80
60
26 60
Practice County Population < 50,000
53
40
50,001-250,000
24
51
> 250,000
20
17
16
0 < 50,000 50,001-250,000 > 250,000
Likewise, 53 percent of graduates from counties with populations of 50,001 to 250,000 and 60 percent of graduates from counties with populations greater than 250,000 practiced in similarly sized communities. In general, dentists practiced in communities that were the same size as those in which they were raised. The results of the odds ratio analyses indicated that graduates who came from a county with a population of 50,000 or fewer were 5.2 times more likely (95 percent confidence interval [CI], 4.0-6.7) to practice in a county with a population of 50,000 or fewer than were their colleagues who came from more urban areas (Table 2). Likewise, graduates from a county with a population of 25,000 or fewer were 5.1 times more likely (95 percent CI, 3.9-6.8) to practice in a county with a population of 25,000 or fewer. For graduates from a town with a population of 10,000 or fewer, the odds were even greater at 5.7 (95 percent CI, 3.8-8.8). Male dentists were 1.4 times (95 percent CI, 1.0-1.8) more likely to practice in a county with a population of 50,000 or fewer compared with female dentists. Findings were similar for smaller counties. Male dentists were 1.3 times (95 percent CI, 0.9-1.8) more likely to practice in a county with a population of 25,000 or fewer and they were 1.2 times (95 percent CI, 0.7-12.0) more likely to practice in a county with a population of 10,000 or fewer than were female dentists.
COUNTY OF ORIGIN SIZE
DISCUSSION Figure 3. Distribution of College of Dentistry at the University of Nebraska Medical Center graduates from 1980-2010, according to size of county of origin and county in which they practiced.
and 2001-2010 decades practiced in counties with populations of 50,000 or fewer. Thirty-eight percent of the 1991-2000 graduates practiced in counties with populations of 50,000 or fewer. Overall, the study’s results show that approximately 35 percent of the 1980-2010 graduates practiced in counties with populations of 50,000 or fewer. The percentage of dentists who came from and practiced in various-sized counties is shown in Figure 3. Fifty-one percent of the graduates from counties with populations of 50,000 or fewer practiced in counties of the same size. 1016
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Although the results of a number of studies in the medical literature have shown that physicians who grow up in small towns tend to practice in small towns,25-27 no such workforce studies relative to dentistry have been conducted. The results of our study of 31 years of students’ records from UNMC COD suggest trends in regard to practice location. Dentists who were from rural communities (counties with a population of 50,000 or fewer) were more likely to practice in rural communities than were their colleagues who were from urban areas (counties with populations greater than 50,000). Dentists tend to practice in communities of the same size as those in which they were raised. Dentists from counties with populations
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TRENDS TABLE 2 of 10,000 or fewer were almost six times Odds ratios for graduates from the College of more likely than were Dentistry at the University of Nebraska Medical dentists from urban areas to return to a Center who practiced in a county that was the same similar-sized commusize as their county of origin. nity, and dentists COUNTY POPULATION ODDS RATIO 95% CONFIDENCE INTERVAL from counties with populations of 50,000 ≤ 50,000 5.2 4.0-6.7 or fewer were approxi- ≤ 25,000 5.1 3.9-6.8 mately five times ≤ 10,000 5.7 3.8-8.8 more likely than were dentists from urban areas to return to a similar-sized community. nities and challenges of rural practice. In addiFemale dentists were only slightly less likely tion, teledentistry consultations with COD speto practice in a rural county than were their cialists from rural sites, as well as state student male colleagues. As the county population beloan and loan repayment programs, have concame smaller, the odds of female dentists practributed to attracting dental school graduates to ticing in such counties were greater. This practice in rural areas (Curtis Kuster, DDS, MS, finding calls into question the conventional admissions director, University of Nebraska wisdom that male dentists are more likely to Medical Center, College of Dentistry, oral compractice in rural communities. In the early munication, April 4, 2011). Approximately one to 1980s, fewer than 3 percent of the dentists in two dental students in each graduating class the United States were women. Currently, participate annually in the state student loan female dentists may be graduating in sufficient program (Merlyn Vogt, DDS, admissions numbers to draw meaningful conclusions director, College of Dentistry, University of regarding their practice patterns. Also, these Nebraska Medical Center, oral communication, practice patterns are in stark contrast with March 12, 2012). Although we did not consider the challenges of recruiting rural applicants, those of female physicians, who according to the student recruitment, the loan repayment promedical literature are significantly more likely to practice in urban areas.30-32 These practice gram and other rural recruitment incentives patterns warrant further research, especially as warrant additional research. the number of female dentists continues to Our study was not a longitudinal study, but increase. rather a study at one point in time. We classified The limitations of this study are that these recent graduates enrolled in advanced education findings are only from one Midwestern dental programs or those with military obligations acschool—UNMC COD. Other dental schools may cording to the size of the community in which have different data. The UNMC COD is a public they were working. Approximately one-third of school, which may have influenced the type of all UNMC COD graduates continued their eduapplicants who were admitted to the program, cation by means of an advanced-degree program as well as the student loan debt burden dentists or had a military obligation (Merlyn Vogt, DDS, have when they graduate. Future studies admissions director, College of Dentistry, Uniinvolving the same retrospective data analysis versity of Nebraska Medical Center, oral comin an urban dental school (public or private) munication, March 12, 2012). Therefore, the may address the limitations of our study. findings for the 2000-2010 period are likely more The UNMC COD has instituted programs to significant than what we reported, as graduates actively recruit applicants from rural communifrom those years generally practice in urban setties for more than two decades. These programs tings for two to three years until they relocate to have included, but are not limited to, summer and practice in a community of their choice. enrichment programs, state college programs Although we have worked with rural dentists for students with minimum grade point average for many years and received requests for assistrequirements for guaranteed admission to denance in identifying students or recent graduates tal school, and targeted recruitment of students who would be a “good fit” for a specific commufrom rural schools. These programs have comnity, we did not address dental care provider plemented the dental school curriculum that recruitment or retention efforts in our study. In requires rural externships. These externships some instances a rural dentist may be the only allow dental students to experience the opportudentist in the county and therefore may view JADA 143(9)
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TRENDS
the sale of his or her practice as not only a business transaction but a continuing legacy of service to the community. These topics may warrant future research to determine why dentists practice and live in rural communities, as well as what criteria rural dentists consider important when selling their practices. This study’s results were limited to one Midwestern dental school, but they support the following general findings: drural dentists should consider recruiting or selling their practices to dentists from rural areas; dsuch dentists can be either male or female, which is in contrast to medicine, in which male physicians are more likely to practice in rural areas than are female physicians; ddental schools may need to admit more dental students from rural areas to address the shortage of dentists in rural areas. The results of this study indicate that a Midwestern dental school can have a significant influence on regional workforce needs. Although students from 38 states were admitted, they went on to practice in 44 states. Most practiced in Nebraska or other states in the region. Rural dentists who want to sell their practices should consider dentists from all dental schools within a multistate region as prospective purchasers of their practices. Likewise, dental school administrators may want to consider accepting qualified applicants from rural areas, regardless of whether they are in-state or out-of-state applicants. CONCLUSIONS
The results of our analyses suggest that the size of the community from which a dental student originates is a significant factor in determining where he or she practices. In general, dentists tend to practice in the same-sized community as that in which they were raised. Male dentists were only slightly more likely to practice in a rural community than were female dentists. Dentists who are considering hiring an associate or selling their practices may want to consider the size of the community in which the prospective associate or colleague was raised, in addition to actively recruiting and encouraging local young people to consider dentistry as a career. Likewise, the administrators of dental schools, depending on their university’s mission and regional workforce needs, may want to focus more or less attention on dental student applicants who come from rural areas. ■ Disclosure. None of the authors reported any disclosures.
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The authors thank Mr. Kim Theesen for formatting the graphics included in the manuscript and Mrs. Debra Rodaway for her assistance with data collection and entry. 1. American Dental Association (ADA) Survey Center. Distribution of Dentists in the United States by Region and State, 2009. Chicago: American Dental Association; 2010:26. 2. Beazoglou T, Bailit H, Brown LJ. Selling your practice at retirement: are there problems ahead? JADA 2000;131(12):1693-1698. 3. Brown JB, Lazar V. Dentist work force and educational pipeline. JADA 1998;129:1700-1707. 4. U.S. Department of Health and Human Services, Bureau of Health Professions. Seventh Report to the President and Congress on the State of Health Personnel in the United States. Washington: U.S. Department of Health and Human Services; 1991. 5. American Association of Dental Schools. Deans briefing book: Academic year,1991-1992. Washington: American Association of Dental Schools; 1992. 6. American Dental Association Survey Center. Academic Programs, Enrollment, and Graduates. Chicago: American Dental Association; 2011:45. 2009-2010 Survey of Dental Education; vol. 1. 7. Guthrie D, Valachovic RW, Brown LJ. The impact of new dental schools on the dental workforce through 2022. J Dent Educ 2009; 73:1353-1360. 8. Urban and rural definitions, released Oct. 1995. U.S. Census Bureau. www.census.gov/population/censusdata/urdef.txt. Accessed July 3, 2012. 9. U.S. Department of Health and Human Services, Health Resources and Services Administration, The Office of Rural Health Policy. Office of Rural Health Policy Rural Guide to Federal Health Professions Funding. Rockville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy; 2011:2. 10. National Rural Health Association. Recruitment and Retention of a Quality Health Workforce in Rural Areas: A series of Policy Papers on the Rural Health Careers Pipeline, Number 4—Oral Health (issue paper). November 2006. Kansas City, Mo.: National Rural Health Association; 2006:1-3. 11. U.S. Institute of Medicine, Committee on the Future of Rural Health Care. Quality Through Collaboration: The Future of Rural Health. Washington: National Academies Press; 2004:1-2. 12. U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Professions. Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. http://bhpr.hrsa.gov/shortage. Accessed July 12, 2012. 13. Kuthy RA, McKernan SC, Hand JS, Johnsen DC. Dentist workforce trends in a primarily rural state: Iowa—1997-2007. JADA 2009; 40(12):1527-1534. 14. The Henry J. Kaiser Family Foundation. State Health Facts.org: Nebraska—dentists. www.statehealthfacts.org/profileind.jsp? cmprgn=7&cat=8&rgn=29&sub=104. Accessed July 31, 2012. 15. Mueller K, Nayar P, Shaw-Sutherland K, et al. “A Critical Match”: Nebraska’s Health Workforce Planning Project Final Report. Omaha, Neb.: Nebraska Center for Rural Health Research, University of Nebraska Medical Center College of Public Health; 2009. www.unmc.edu/rural/documents/NebraskaWorkforceProjectFinal 091509.pdf. Accessed July 5, 2012. 16. The Henry J. Kaiser Family Foundation. State Health Facts.org: Wyoming—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?cmprgn=29&cat=8&rgn=52 &ind=966&sub=104. Accessed July 31, 2012. 17. University of Washington Center for Health Workforce Studies. Data Snapshot: Wyoming Dentists, 2009. http://depts.washington.edu/ uwrhrc/uploads/WY_Dentists_DS.pdf. Accessed July 5, 2012. 18. The Henry J. Kaiser Family Foundation. State Health Facts.org: South Dakota—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?ind=966&cat=8&rgn=43. Accessed July 31, 2012. 19. The Henry J. Kaiser Family Foundation. State Health Facts.org: Kansas—dentists per 10,000 civilian population, 2007. www.statehealthfacts.org/profileind.jsp?ind=966&cat=8&rgn=18. Accessed Aug. 2, 2012. 20. South Dakota Department of Health. 2011 Healthcare Workforce Report. http://doh.sd.gov/RuralHealth/Workforce/ 2011WorkforceReport.pdf. Accessed July 5, 2012. 21. Kansas Department of Health and Environment, Bureau of Oral Health. Kansas 2009 Oral Health Workforce Assessment.
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www.kdheks.gov/ohi/download/2009_Oral_Health_Workforce_ Assessment.pdf. Accessed July 5, 2012. 22. Haden NK, Catalanotto FA, Alexander CJ, et al. Improving the oral health status of all Americans: roles and responsibilities of academic dental institutions: the report of the ADEA President’s Commission. J Dent Ed 2003;67(5):563-583. 23. Davidson PL, Carreon DC, Baumeister SE, et al. Influence of contextual environment and community-based dental education on practice plans of graduating seniors. J Dent Edu 2007;71(3):403-418. 24. Formicola A, Bailit H, D’Abreu K, et al. The Dental Pipeline program’s impact on access disparities and student diversity. JADA 2009;140(3):346-353. 25. Seifer SD, Vranizan K, Grumbach K. Graduate medical education and physician practice location: implications for physician workforce policy. JAMA 1995;274(9):685-691. 26. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase rural physician supply: a systematic review and projected impact of widespread replication. Acad Med 2008;83(3):235-243.
27. Pepper CM, Sandefer RH, Gray MJ. Recruiting and retaining physicians in very rural areas. J Rural Health 2010;26(2):196-200. 28. Wall TP, Brown LJ. The urban and rural distribution of dentists, 2000. JADA 2007;138(7):1003-1011. 29. American Dental Association. Dental Workforce Model Report: Distribution of Dentists in the United States by Region and State. Chicago: American Dental Association; 2006. 30. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ. Increasing the supply of women physicians in rural areas: outcomes of a medical school rural program. J Am Board Fam Med 2011;24(6): 740-744. 31. Spenny ML, Ellsbury KF. Perceptions of practice among rural family physicians: is there a gender difference? J Am Board Fam Pract 2000;13(3):183-187. 32. Glasser M, Hunsaker M, Sweet K, MacDowell M, Meurer M. A comprehensive medical education program response to rural primary care needs. Acad Med 2008;83(10):952-961. 33. Brown LJ. Dental work force strategies during a period of change and uncertainty. J Dent Educ 2001;65(12):1404-1416.
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