ISSUE
               
Part II of the Emerging Debate on the Role of
Research in Dental Education and the Profession

Dental Education: Immune to Change or
Up to the Task of Regenerative Reform?
- Dr. R. Bruce Donoff


R. Bruce Donoff, DMD, MD Dean, Harvard School of Dental Medicine








Dean R. Bruce Donoff and the HSDM 2010 Dean's Scholars




In 1998, I attended a meeting of the American Association of Dental Schools (AADS), now the American Dental Education Association (ADEA), entitled "Leadership for the Future: The Dental School in the University." The meeting brought together dental school deans and university administrators to lay the foundation for greater university-dental school partnership and collaboration.

After the publication in 2000 of Oral Health in America: A Report of the Surgeon General - the first-ever surgeon general's report on oral health-hopes were high for continued growth of an infrastructure and commitment to research leading to decreased oral and craniofacial disease. These hopes were strengthened by the 2001 "Future of Dentistry Report," which stated that "the nation's dental schools are the practicing profession's sole link to the university and with it the esteem and professional stature that dentistry enjoys." That fact above all else makes it a profession.

More recently, the results of the three-year Macy Foundation Study, "New Models of Dental Education," were presented in 2007 at Emory University and the proceedings were published in a February 2008 supplement to the Journal of Dental Education.

The principles underlying educational reform in dental education as defined by the Macy Foundation Study bear repeating here:

  • Dentistry is a learned, self-regulating profession that is comparable to but organizationally separate from medicine.
  • Every dental school must be an integral part of a university, and the majority must be based at research-intensive universities, where faculty scholars advance the sciences underlying the practice of dentistry and pass this knowledge on to students, residents, and others.
  • Dental schools must have the resources needed to:
    • Recruit and retain adequate numbers of well-qualified faculty;
    • provide faculty with sufficient income, space, equipment, time, and administrative support to pursue their scholarly activities;
    • recruit and maintain a diverse student body and faculty;
    • maintain their physical plants;
    • invest in new educational technologies and learning resources.
  • The teaching, research, and service programs of all dental schools must contribute to reducing oral health disparities.
  • Dental students need the same basic understanding of human biology and behavior as medical students and advanced knowledge of the basic, social, and clinical sciences relevant to the diagnosis, prevention, and treatment of oral disease/conditions in health and medically compromised patients.
  • Clinical training should include adequate time in community-based, patient-centered delivery sites, providing evidence-based care to diverse groups of patients, efficiently.
  • The curriculum should prepare graduates to enter practice; however, in the future, this could shift to preparing students to enter general or specialty residency programs.

Yet today, the strength and potential of the nation's dental schools to advance the stature of the profession has markedly decreased. A key reason is that between 1982 and 2000 seven dental schools closed. While four dental schools have opened since 2000 and several more are scheduled to open in the near future, many dental school deans are concerned that the new schools appear to be embarking on a path that reduces the school's commitment to scholarship and service and lacks a close partnership with the mission of the universities in which they reside.

This development is both ironic and sad: Ironic because dentistry has become a compelling career choice for an academically ever-improving group of applicants; sad, because the expansion of the applicant pool appears to be driven largely by a profit motive. Simply put, today's dental school applicants look forward to higher practice incomes than any previous generation of dental graduates. Accordingly, they are focused strongly on private practice careers to the exclusion of other options. We need to find those applicants interested in careers in dental education to provide for a future workforce that is anchored in scholarship and evidence that can be translated for appropriate diagnosis, prevention, and treatment.

The new dental education landscape was the topic of a meeting held last May in Ann Arbor at the University of Michigan School of Dentistry. Notably, the meeting has spurred a great deal of discussion and controversy, which did not occur following the 1995 IOM Report on "Dentistry at the Crossroads," the 1998 AADS (now ADEA) Conference on "The Dental School in the University," and the very clear-cut Macy Foundation Study. The reason seems to be that schools which value research and scholarship met as a separate group and some schools were not invited. Those not included have raised questions about this process.

To my mind, the controversy should not be about labels-non-research-intensive, research-intensive, clinically intensive-but about the content and form of the education offered. I am convinced that it should be about the importance of dentistry viewing itself as a branch of medicine and not permitting market values to overshadow the academic values of education, research, and patient care. I believe that with the rise of the new schools, there has been a reduction in the "gold standard" of teaching: Direct student-teacher and supervised student-patient interaction has been replaced by a potpourri of online and simulated modules. We need to link education and research evidence to a model of mentorship, collegial team support, and the primary doctor-patient relationship. We need to recognize that training is preparation for a set way of doing things; it aims at a stable objective, while education is the art of dealing with knowledge. We need to be in the business of education.

At the Ann Arbor meeting, Dr. Larry Tabak, then Director of the National Institute for Dental and Craniofacial Research (NIDCR), who was recently promoted to Principal Deputy Director of the entire National Institutes of Health (NIH), expressed his concern that American dental schools would be unable to educate and train the dental scientists of the future. He specifically lamented the possibility that the new schools will cause the profession to lose esteem-to regress in the public's mind from a profession to a vocation. He also cited the fact that more government research dollars are currently going to non-dentist scientists than to dentist-scientists. Dr. Tabak's promotion is a feather in the cap of all of dentistry, and his views are extremely relevant. But let me note that while I agree with him in the first case, I see the fact of NIDCR funds going increasingly to non-dentist scientists as a reflection of the greater general interest in the dental and craniofacial areas as models for studying the mechanisms of disease, be it inflammation, mechanical forces on hard tissue, or genetic models of disease. However, it may also reflect fewer competitively qualified dental applicants for NIDCR funds.

Be that as it may, I am convinced that it is past time for dentistry to sort out the differences between professional and vocational education. In this regard, I have written of the need for a new Gies Report to advance dental education and the profession, just as the Gies Report of 1926 did. If a new Gies Report were to be written today it would surely insist that quality dental education be built on:

  • A faculty that actively engages in scholarship to assure that the profession continues to progress and does not become a trade.
  • Functional integration with the university, academic health centers, and community health centers, as these are the centers of learning in health professions.
  • A faculty that actively engages in providing health care with a primary mission of public service.
  • A curriculum that promotes learning through active participation rather than through learning of factual and technical knowledge only.

How can we hope that the new schools with purportedly new educational models but with a very high cost to students (and a loan system that is overtaxed) will advance dentistry's stature as a profession, as well as alter the workforce model currently in effect?

In his keynote address to the 2007 Macy Foundation meeting, Bernard Machen used the community college model as a metaphor for dental education that does not prize research to explain how lowering the cost of dental education would not keep graduates on a par with other professions. So a giant issue is finding the financial resources needed to function successfully in a research university environment. The new schools rely on outsourced science teaching, community clinics, and tuition as the primary business model. Compare that with NYU, which has parlayed large class size and tuition revenue into major recruitment of faculty, including scientists. So maybe one way forward is to enlarge the capability of existing dental schools to work in both the clinical and research-intensive worlds. There are no research-intensive dental schools that fail to produce competent dentists.

As Vannevar Bush, President Roosevelt's wartime science advisor, said in his 1939 MIT baccalaureate address entitled "Opportunity for the Professions": "It is apparent that medical care, including dentistry, can be made available on an adequate plan to the entire population, only if traditional procedures are somewhat altered and adapted. The time and effort of men trained at great expense to society cannot be wasted on anything which can be safely delegated under supervision to those of lesser training."

We have an opportunity, given the development of mid-level providers, to examine the best way to integrate both scientific learning and expanded access to community care into oral healthcare delivery. It is interesting to me that, while a cardiac surgical resident, my main job in the OR was to harvest leg veins to be used in coronary artery bypass grafting. Physician assistants now do this. The growth of nurse anesthetists presents issues similar to those involving dental mid-level providers.

I am a great fan of Jim Collins of Good to Great fame. His concept of catalytic mechanisms is very attractive to me and has proven sound. "Great organizations," he writes, "have figured something out. The old adage, ‘People are your most important asset' is wrong; the right people are your most important asset. The right people are those who would exhibit the desired behaviors anyway, as a natural extension of their character and attitude, regardless of any control and incentive system. The challenge is not to train all people to share your core values. The real challenge is to find people who already share your core values and to create catalytic mechanisms that so strongly reinforce those values that the people who don't share them either never get hired or, if they do, they self-eject."

Many change programs trumpet their arrival with well-known Big Hairy Audacious Goals (BHAGs). But many get stuck at the first obstacle to meeting those goals-that of mobilizing the organization away from the status quo. Truly catalytic mechanisms help catapult organizations over this hurdle. This simple yet powerful tool enables companies to propel commitment levels past the point of no return. They are galvanizing, non-bureaucratic means of turning visions into reality, usually involving a redistribution of power. The key impacts of catalytic mechanisms are:

  • They produce unpredictable results.
  • They redistribute power away from traditional power-holders and toward the overall system.
  • They have sharp teeth.
  • They attract the right people and eject viruses.
  • They produce an ongoing effect.

Many managers get stuck ceaselessly drafting vision statements. A catalytic mechanism, however, establishes a tangible process that all but guarantees that the vision will be fulfilled. Speeches, off-site meetings, and crises can mobilize people, but the effects seldom last once the excitement dies down because true adaptive change means loss of authority or power for some group. Since catalytic mechanisms provide no escape route and require 100 percent commitment, their results can last for decades. Maybe Ann Arbor was such a catalytic mechanism.

Where Do We Go After Ann Arbor?

So what should we do to maximize the catalytic potential of that forum? Almost everyone believes that the future of the profession belongs to dental education, but are we up to the task of working collaboratively-new schools and traditional schools alike-working together for the best future for the profession and the public? The argument that 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 is weak if we recall Vannevar Bush's admonition of 1939. More dental graduates do not ensure more practitioners in underserved communities.

The following are some suggested action items that may help us bridge the divide that currently confronts dental education. In particular is the elimination of live patient licensure exams, which has been a topic of discussion for years with a resolution passed nationally to eliminate. So where are we? We still see dental students scrounging for patients, paying patients and assistants to sit for an exam, while organized dentistry touts ethics in the curriculum. How disingenuous.

Below are some things we can do to catalyze change.

  • Work with the Friends of the NIDCR and Congress to promote increased funding to the Institute and show how research in epidemiology and health services outcomes, as well as basic biomedical and behavioral science, can improve the oral health and systemic health status of the population.
  • Advocate for funding agencies to consider mechanisms to modify existing funding to promote and support the integration of research in dental education.
  • Urge the NIDCR to offer training grant programs that couple research-intensive dental schools and non-research-intensive schools. Provide incentives in funding mechanisms to facilitate the creation of school consortia for teaching and scholarship.
  • Demonstrate the importance of this to the revised CODA Standard 6.
  • Eliminate live patient exams from licensure.
  • Get all deans of dental schools to agree that elimination of these exams is beneficial and in the interest of the patient; or, even better,
  • Make a mandatory PGY-1 (postgraduate or internship year) a mechanism of licensure nationwide for general practice.
  • Work with individual state regulatory bodies to achieve these changes within three years.
  • Couple new educational models and dental schools with education and training of mid-level providers.
  • Convert current PBRNs (Practice- Based Research Networks) to dental school programs to involve students and faculty more than outside practitioners during the dental school years. Develop pilot projects.

I believe that each of the above actions can be a catalytic mechanism because each will have positive consequences like freeing curricular time for activities of the mind rather than the hands, expanding the base of faculty available to mentor and guide students, enhancing the self- image of dentistry as a profession based upon sound ethical and moral standards that don't change once you get a degree or a license, expanding the diversity of patients treated, and making dental education patient-centered rather than procedure-focused.

Oh, and one more thing-get all dental schools to award a single degree and make it the DMD degree for, as Edward D. Churchill said in the New England Journal of Medicine in 1951, "The most significant trend of the 20th century is that toward cultivating the discipline of mind needed to complement and guide surgical technology."

References

Donoff RB. It is time for a new Gies Report. J. Dent Ed. 70:809, 2006.
Machen JB. Will we allow dentistry to be left behind? Principles underlying dental education and practice. J Dent Ed. 72:10, Supplement February 2008.
Churchill ED. Fifty years of medical progress: medicine progress: medicine as science: surgery. New Eng J Med. 244:799, 1951.
Bush V. Opportunity for the professions. The Tech (Cambridge, MA). June 6, 1939."