There has been considerable conversation and concern raised by some individuals as well as some dental schools about the proliferation of new dental schools. In fact, some have gone so far as to label them "non-research-intensive" schools with an agenda that focuses on education (training) rather than on research, as if the two were mutually exclusive. So, the label "non-research-intensive" has become a pejorative term suggesting or stating outright that these schools pose a threat to the science base of dental education and clinical practice and, therefore, to dentistry's prestige and future. Recently, some of the research-intensive schools held a meeting, excluding the schools they did not believe were research-intensive. I have seen a lot during my 40-plus years in the dental profession. But this exclusion of some schools from a meeting because of the perception that they are not research-intensive is among the most disheartening. Indeed, it strikes me as potentially so divisive and destructive as to pose a serious threat to dental education and its ability to grow, embrace collaboration and change, sustain its prestige, and reinvent its future.
Once the house is divided it can fall, and like a house of cards it can be conquered by a variety of predators, including our own universities, professional organizations, and federal and state regulators and legislators. To be sure, scholarship is vital to maintain a learned profession, and to use the adage of former Congressman Paul Rogers, "Without research, there is no hope."
However, what constitutes research and what defines a research-intensive versus a non-research-intensive school is a matter of considerable debate. Academia has gone through many iterations of defining scholarship. For the purpose of this article, it is critical to define research and scholarship in the broadest manner possible.
Perhaps the most influential event in redefining scholarship occurred following the 1990 publication of Scholarship Reconsidered: Priorities of the Professoriate by Ernest Boyer, former Director of The Carnegie Foundation for the Advancement of Teaching. Boyer advanced four forms of scholarship appropriate for faculty work. These forms included:
- The Scholarship of Discovery - generally what is referred to as research.
- The Scholarship of Integration - generally focuses on interpreting the findings of discovery science in a larger, more comprehensive context. This is where the connections with other disciplines occur and boundaries are blurred.
- The Scholarship of Application - generally focuses on how knowledge can be applied to consequential problems. The Scholarship associated with addressing social issues and problems as well as service flows out of Application.
- The Scholarship of Teaching - teaching as an intellectual activity per se.
There is not sufficient space or time in this short article to discuss these areas in detail. However, translating these definitions, which are widely accepted by the academy, in the context of dental education extends the boundaries of scholarship from pure discovery (biomedical science) to the social and behavioral sciences and to epidemiology, public health, service learning, and education research itself. So, identifying the research-intensive nature of dental schools is not so simple. Diversity in educational programs is the hallmark of the US system, which allows for constant improvement as the dynamics of the nation's needs change according to societal demands and population and economic stresses.
This is the time in the evolution of the dental profession when we should be advocating for aggressive collaboration, cooperation, and partnerships instead of competition for a diminishing pool of resources. It should be a time when we ensure that we educate and graduate scholars, critical thinkers, and lifelong learners across the spectrum of schools and disciplines as well as competent practitioners. Without question, there have been great advances in science fueled, in recent years, by the genome project. Yet, we have a long way to go to realize the promise that emanates from understanding and mapping the human genome. Indeed, there are some dental schools and health centers that have superb biomedical science profiles, but to realize the hope of science to improve the public health, we must reach out to a broader array of individuals and institutions that can assist in accelerating the translation of science to the practitioners and the public. The Practice-Based Research Networks (PBRN) funded by NIDCR are an example of the use of multiple constituents, including the practicing community, to respond to real world problems. Clearly, this activity requires the forging of innovative partnerships among the health professions, industry, the practicing community, and the public sectors and should encompass all the dental schools, not just those perceived to be research-intensive.
At the same time as we are squabbling over who gets invited to the table, it is increasingly clear that the public and legislators care about three things: access to care, quality of care, and cost of care. Cost of care will eventually set boundary limits for access and quality of care, as it does now in so many countries. Going forward, if this is the case, then more than ever there will be a need for dental schools whose mission will be focused on primary care. In addition to providing a complementary, diverse science base to the biomedical research-intensive schools, these new dental schools, as well as some traditional schools, have stepped up to the plate to fill the access, quality, and cost gap by initiating new, more cost-efficient models of education, by advocating for and implementing interprofessional education programs, and by developing community-based education programs that may lead to a cadre of practitioners who will practice in the underserved communities.
Some of the gaps in access reside in educating appropriate numbers of practitioners to address these issues, which stem from the reductions in dental school class size that have taken place in the last two decades.
The drop in dental school graduates from a high of about 6,200 in the eighties to about 4,500 now exacerbates the problem that dental education and the profession face. Interestingly, there are about 10 new dental schools in the process of opening. If each one graduated an average of 80 students, the number of graduates would be about 5,300, which is still a thousand short of the 1980s. At the same time, the US population is exploding - moving from about 300 million now to over 400 million by 2050, a 33 percent increase in population.
As ADEA points out, in addition to the growing oral-systemic health linkages, people are increasingly living longer with improved oral health, so the number of teeth cared for is increasing at a faster rate than the population. The elderly cohort is growing in an exponential manner and so the dentist, increasingly, will be seeing patients with a host of chronic diseases, including diabetes, cardiovascular disease, obesity, pulmonary disease, renal disease, and many others. Future graduates must be better equipped to be able to diagnose, prevent, and treat these complex patients. This requires students who are critical thinkers and lifelong learners and who are facile with medically compromised patients.
In keeping with the broad definition of scholarship, we need to develop better scientific approaches to understand what motivates people to comply with drug therapy, better nutrition and dietary choices, better overall lifestyle choices, and willingness to engage in the personal, participatory wellness medicine of the future. These latter sciences are often not those in the forefront of research-intensive schools, but may be better served in schools at universities where these latter issues are on the front burner, so to speak. To suggest that educating the evidence-based, lifelong learner can only occur in research-intensive-schools is narrow-minded and at odds with CODA standards and the emerging evidence from those new schools.
For example, one of the new schools, Western University of Health Sciences, has created a physical plant that houses interprofessional education programs, of which the dental school is an integral component. Another, the University of Southern Nevada, has added a fifth floor devoted to research in a new building under construction to house the College of Dental Medicine. Yet another, Nova Southeastern University (the oldest of the new schools), has evolved its research program over the past 13 years to the point where a new Dean of Research has been recruited and its students and faculty have received numerous honors for their research, including NIH and Howard Hughes Summer Fellowships.
To my knowledge, every new school that has opened or is in the process of opening has made the integrated biomedical and clinical sciences and scholarship a component of their mission or they would not have received approval from CODA. Accordingly, it seems that this entire debate is premature. Under the best of circumstances, it takes dental schools a significant period of time to develop and sustain a robust research program. The dental school at the University of Texas Health Science Center in San Antonio, for example, took about 20 years to establish a viable, flourishing research program. So, rather than get exorcised over the trend of dental schools opening in non-research-intensive universities, let's be collegial and give them a chance to develop, or even better, give them a hand to accelerate their research programs, rather than run off and exclude them from meetings! To reiterate, we should drop the insecurity and preach collegiality, cooperation, and partnerships with our sister schools.
In many ways, as a profession, we have been our own worst enemies. For example:
- We have elected to stay out of Medicare funding.
- We have not been successful in ensuring that adults are covered by Medicaid.
- We have not been successful in convincing enough dentists that they have an ethical and moral imperative to accept Medicaid or public assistance patients.
- We have fought the introduction of new providers (although alternative providers are emerging).
- We have largely ignored the monumental oral health problems of Native Americans.
- We have not addressed effectively the ethnic and social oral health disparities in the population.
- We have been unsuccessful in convincing or inspiring our graduates to pursue careers in academics and research (less than 0.2 percent of graduating seniors continue to indicate they would enter a career in research).
- We have not challenged effectively the arcane and outdated national and state licensing examination structure which impedes the movement of practitioners to areas of need.
- We continue to have dysfunctional professional dental organizations.
- We have not embraced education reform (there has been much reform talk with little change).
- We have not developed cost-effective models of education and clinical care.
- We have not developed a viable, tested business model to enable dentists to practice in underserved areas.
- We have not done enough to engage the dental hygienist and the allied health professions as partners in caring for patients.
- We have not been successful in employing evidence-based approaches to education and clinical care.
- We have not addressed effectively a procedure-based reimbursement system which impedes movement from a surgical to medical model of practice.
- We have been unable to develop improved diagnostic codes.
- We have done a poor job at epidemiologic data collection.
- We have not experimented enough with novel ways to educate dental students and provide opportunities for graduates to embrace the notion of a primary care provider functioning as an integral part of the healthcare team.
- We have not been successful in convincing the Stanford universities of the world that dental education is a vital part of health care and thus deserves a place in these institutions.
Importantly, all of these "we have not's" and the current state of dental education are a result of the input of the present university and health science center-based dental schools, which include the current research-intensive schools.
The complex issues facing dentistry today - healthcare reform, access to care, quality of care, cost of care, new practitioners, oral-systemic health linkages, and others - will have profound influences on dental education and dentistry's role in society in the coming decades. So, this is the time to embrace coalitions, strategic partnerships, and cooperation in order to use, effectively, the considerable talent available in all of the dental schools and health professional schools to address the needs of the public.
It is not a time to segment the schools into artificial categories. Perhaps a refresher lesson would be instructive. In the 1990s, the dental schools fought and won a successful battle to keep US News and World Report from ranking dental schools. We won because we were strident in our view that the methods the magazine used to rank schools were inappropriate and undefined. Fast forward to today when we are being asked, by a select group of schools, to allow them to identify themselves as the institutions that will lead the profession into the future. So, a number of questions come to mind:
- How do you identify who should be invited to the meeting?
- How do you define research-intensive? Is it more than one NIH Research Project Grant (R01)? Is it more than three R01s? Is it based on a threshold of NIH/NSF dollars, e.g., $1 million? Is it those schools that are a part of the Clinical and Translational Science Awards Program (CTSAs)? Is it publishing in refereed journals with high impact value? Is it further segmented into the institutions that publish in Cell, Science, and The New England Journal of Medicine?
- How do schools fare in this "segmented academy" when their research diminishes? Are they pushed out of the tent?
- How do you treat schools that have primary research profiles with industry and/or foundations and little or no federal funding?
- How do you account for the lack of research productivity by about 30-plus traditional schools that have limited or no NIH funds?
- Are the institutions that are not dental schools (such as medical schools) invited to the party because they receive collectively about 40 percent or more of NIDCR funds?
- Shouldn't we be concentrating on how to increase research productivity and efficiency and reducing the cost of research?
- Where is the evidence that there is a shift in emphasis from research to teaching in these new schools?
- Where is the evidence that graduates of any school will remain evidence-based a generation after they graduate?
- What role does behavioral, social, and population-based science play in this select group of schools?
- How will this group address the issues of the day: access, quality, and cost of care?
The questions are endless and the debate is both pointless and destructive. The truth is that it is not so simple to ensure dentistry's future. It is not a matter of who writes the next Gies Report. This is a time not for exclusives but for collaboration, cooperation, and partnerships. A few examples may help:
- Develop joint training programs for the cadre of faculty equipped with the necessary skills for the future with schools that have complementary research and education.
- Develop bidirectional opportunities for students to spend time in other institutions to gain from the research and technology strengths of these institutions; and for other students to learn about public health, community care, health promotion, and alternative education models from schools that have these complementary strengths.
- Develop individual Information Technology (IT) programs that educate faculty in contemporary forms of scholarship.
- Develop interprofessional and interdisciplinary education, research, and clinical care programs across schools and professions.
- Develop new approaches to dental education, quality, and cost of care.
- Develop cross-school community-based clinical programs where students work side-by-side with community healthcare advocates, social workers, and patient navigators to bring care to the underserved.
- Develop joint degree programs with institutions with complementary strengths in non-traditional areas at the interface of disciplines and where discipline boundaries are blurred.
- Work with complementary schools and individuals to embrace and invest in new diagnostics, prevention, and therapeutics that result in more rapid translation of science to community.
- Work with complementary schools to improve teaching effectiveness.
- Others . . . .
What can we learn from the new schools?
- New approaches to dental education and clinical care delivery that result in reduction in costs without compromising quality.
- New focus on interprofessional and interdisciplinary education.
- New organization development models where traditional department structure does not exist and silos can be diminished.
- Novel approaches to recruitment of students whose values include caring for the underserved in a culturally competent environment.
- Novel approaches to community-based education and interdisciplinary health care.
- Novel mastery learning, block system of education, and continuous assessment methods that include formative and summative assessments.
- Creative ways to share faculty resources from multiple disciplines and health professions institutions.
- Creative approaches to public health, primary care, health promotion, disease prevention, and personal, participatory dental medicine.
- New approaches to incorporating new information technology and social networking into dental education.
- Novel ways to increase student clinical productivity.
- Incorporation of interactive, Web-based instruction into the basic science and preclinical curriculum.
Perhaps Malcolm Gladwell said it best when commenting on the US dental healthcare system. He wrote that when the public is asked about their first priority in universal health coverage, the immediate answer is almost always "my teeth."*
The pain, discomfort, and disfigurement of poor oral health leads to self-consciousness, low self-esteem, low educational achievement and even slow or faulty intellectual development. Poor teeth are an outward marker of class. As we are nearing adding more children and adults into an already tired and failed healthcare system, the issues of access, quality, and cost of care are sure to escalate. In spite of the improvements in efficiency of practice, we will undoubtedly need more dentists, dental hygienists, dental assistants, and new practitioners with clinical skills that provide the oral healthcare team more flexibility in meeting the needs of the public. So, the new schools, if they do nothing else, can add people to the workforce who are necessary to meet the future oral health needs of society. Clearly, this is the primary mission of dental schools - to educate caring, evidence-based, competent professionals in sufficient numbers to address the oral health needs of the growing population. Indeed, the new dental schools may add a diversity of educational backgrounds that may preselect those students interested in research to seek further education, in effect shifting research from the predoctoral to the post-graduate level or creating dual educational pathways.
All dental schools and their parent institutions must come to grips with their existing strengths and weaknesses and identify how they can partner with complementary institutions so that, collectively, we can ensure meaningful and substantial contributions to the learned professions. It''s not simple, but it requires a spirit of inventiveness, cooperation, collegiality, and partnerships where everyone is invited to the table in an open, fresh discussion. As Einstein is reported to have said, "We need to not think more but we need to think differently"! Collegiality and partnerships should be the injunction for the future!
*Gladwell, M. "The moral-hazard myth: The bad idea behind our failed health care system." The New Yorker. August 29, 2005.