The summer 2010 issue of Global Health Nexus raised some important issues about the current and future state of dental education. For the most part, the concerns centered around the notion that dentistry's status as a learned profession may be adversely affected by new dental schools and some existing dental schools that place inadequate emphasis on the scientific research element of their academic missions. Apparently, the fear is that this trend may shift the balance between research-intensive and non-research-intensive schools, engendering the perception that dentistry is a trade, not a profession. The argument(s) for this position were proffered at a meeting last May in Ann Arbor, Michigan, where the "research-intensive" dental schools declared that they must lead the profession into the future.
The premise was that the new dental schools may be de-emphasizing or ignoring science, and, therefore, not linking research and discovery to patient care. As noble as the Ann Arbor meeting's intention may have been, it resulted in a version of the famed Apollo 13 adage, "Houston, we have a problem!" The problem is simple: Without all the dental schools at the table to discuss these important issues, communications were incomplete and inconclusive, and misunderstanding, divisiveness, and disunity were inevitable.
At the outset, we want to emphasize our strong commitment to mission balance, or to put it another way, to an appropriate emphasis on education, research, patient care, and community service consistent with a school's environment. The Greek mythological figure Procrustes, famed for his "one-size-fits-all" approach to providing the perfectly sized bed for his visitors-by stretching them on a rack to make them fit the bed or chopping off their legs if they were too long for the bed-has never been a guide to formulating academic missions. Simply put, there is no single template for mission design. Some schools are essentially freestanding; some are located in great research universities or academic health centers. Academic missions vary as a function of academic settings and the needs of surrounding communities.
The Abilene Paradox
The exclusivity of the Ann Arbor meeting, the failure to include all schools and therefore all types of dental school missions in the discussions, has, in our opinion, resulted in a classic case of "mismanaged agreement," as exemplified in the story "The Road to Abilene," which is often cited by management and business experts to demonstrate the perils of "groupthink." Here's what happens:
Four friends are seated at a table on an August Sunday afternoon in Wichita Falls, Texas, playing dominoes. They are in perfectly comfortable surroundings-plenty of beer, nachos, and other food as well as air-conditioning. Someone makes a halfhearted suggestion that they go to Abilene-55 miles away-for dinner at the local café, which does not have a Michelin rating. The others demure, saying unenthusiastically, "We're okay here." The suggestion emerges again and is again mildly rejected. Then another player says, "Maybe we should go to Abilene." The responses remain remarkably unenthusiastic, but eventually all four end up in the car on a 55-mile-long drive during which the air-conditioning fails. It is dirty; it is hot; and the food is even worse than they remembered. On the return trip, an argument erupts. "Whose idea was this anyway?" someone asks. "I'm hot, dirty, and my gut aches." Each blames the other for a bad decision.
At the domino table before departure, there was no strong advocacy for driving to dinner at the cafe, and the group had a tacit agreement that remaining in Wichita Falls was best. But they mismanaged the agreement and ended up on the Road to Abilene because of a breakdown of group communication. The business and management community considers this sort of mismanaged agreement, known as the Abilene paradox, to be more serious than actual disagreement because the former is considerably more wasteful and disruptive.
It is, therefore, incumbent upon us to avoid the mismanagement of the research-intensiveness issue. We believe there is general agreement concerning the critical nature of research and scholarship, broadly defined, in dental education. However, the essential premise of the argument, that new schools are non-research-intensive, is specious. Indeed, the entire matter appears to be a classic example of the mismanaged agreement.
To our knowledge, no one supports the concept of creating new schools without a commitment to research and scholarship; and everyone accepts that a variety of mission profiles among dental schools is actually healthy. For the most part, research, teaching, patient care/ community outreach, are appropriately emphasized within dental education. Consensus on this issue would help us avoid the Abilene paradox and promote collaborations to ensure that dental education as a whole fulfills all three mission elements, with different emphases on these elements among the various schools.
It is important to note that considerations such as the specific geographic locations of dental schools, the socioeconomic status of the communities they serve, their home as a relative stand-alone institution or as a component of an academic health center, will play major roles in determining their profile in research, teaching, and patient care/service. In some cases, the emphasis is on pure biomedical research; in others, it is on health services research, or public health research, or corporate support of product testing research; or behavioral and attitudinal research; or educational research; while in others, it is a blend of various research agendas. Scientific discovery and/or the application of scientific advancements all have a place within dental education's mission. Mission balance, therefore, encompasses education, clinical care, and research and scholarship. One institution's strengths may be another's weakness, so it makes good sense to develop academic partnerships or inter-institutional collaborations to advance the common good.
The relationship of dental schools and their parent universities to the communities they serve and to the representatives of those communities derives from an ancient social contract: Academic institutions conduct education, research, and clinical care programs to address societal needs; and society, perceiving the benefits of these programs, reciprocates with support for academic institutions. Unfortunately, it is difficult for the public to appreciate the research agenda when the need and demand for care are so prevalent. That is not to say that the public does not appreciate the need for research but, for the most part, it values more tangible things, which can be measured, like community and schools-based prevention programs and direct patient care. So, the "value proposition" of a dental school and academic health center has been questioned in terms of whether or not the dental school and academic health center "advances and applies knowledge to improve health."1 This public trust, and the community and legislative support it elicits, must be vigilantly nurtured; failure to do so places this critically important support at risk.
There is a great need, therefore, to appreciate the necessity of developing community partnerships to better understand the broad factors that influence an individual's health prospects, including genetic makeup, social circumstances, environmental conditions, behavioral choice, and medical/dental care.2 The "siloed" nature of many of the health professions schools has contributed to a limited understanding of this complex array of health determinants and the necessity of partnering for the common good. What the dental profession does not need is further division and conflict; i.e., a breach between research-intensive and non-research-intensive schools. This conflict can only be destructive in the long run and will ultimately defeat its very purpose, as proffered at the Ann Arbor meeting-the advancement and preservation of dentistry as a learned profession. Instead, the call should be for creating innovative partnerships among the various schools with their different ways of achieving mission balance to determine how best research and scholarship could be advanced for all the participants and how the profession as a whole can ensure improvement in the health of the public. It occurs to us that in addition to basic biologic and biomedical research, a number of other research and scholarship priorities are and/or should be taking place in many dental schools and/or their parent institutions. Some limited examples include:
- Educational research. For the most part, we are still educating students in traditional methodology while students are learning through multiple information technology and social networking venues.
- Behavioral research. Attitudes, health behaviors, and social determinants of health are not reflected well in the portfolios of dental educators and oral health scientists.
- Interprofessional education research. There is a great deal of discussion about inter-professional education. Where is the evidence that it will be more or less effective than current models of health professions education and is there any evidence that patient health outcomes will be improved?
- Workforce research. The issues of access to care, cost of care, and quality of care are at the heart of the public trust and societal demands and so research on new workforce models merits considerable attention.
- Faculty development research. The great need is not only to convince students that they should seek a career in academics, but when they get there, they need to be able to survive the antiquated publish-or-perish culture. How do we develop such faculty for the future?
- Cost of dental education research. Is there a better and/or more cost-effective way to provide dental education? Do some of the answers lie in the new school models? Is the current model of financing dental education sustainable? This is a critical area that is ripe for scholarship and research.
- Epidemiological and population-based research. With the profound changes in population growth and with significant demographic shifts in the population in terms of age and ethnic minority shifts, there is a vast chasm for research to fill.
- Women's Health Research. There is a contemporary NIH report on a new vision for women's health research. The research agenda focus is on taking advantage of the synergy between cutting-edge technology and novel concepts to advance women's health and sex difference in research through inter- and multi-disciplinary collaborations.3 There is much research to do here as well.
- Global health research. With globalization, the world is indeed flat and the people in it are moving across the world in increasing numbers, which increases the possibility of infectious disease transmission. Coupled with changes in diets and nutrition, and with almost ubiquitous poverty in some countries, the issue of global health requires significant attention.
These illustrations are meant only as examples of the breadth and depth of scholarship and research that could, should, and, in many cases, are taking place in dental education. It is important to emphasize the importance of exploration, experimentation, and innovation in new models of education to ensure long-term viability of our programs and, perhaps, through more efficient education programs, permit the reallocation of some resources to support other mission elements. To put it another way, there is inherent value in health services research, educational research, and many other kinds of research.
A Call for Unity
If there are threats and challenges, we should address them in a unified fashion. There is tremendous opportunity for the dental education community to seize an even more important role in leading the profession. In doing so, we could create long overdue reforms in public health policy, reforms in licensure and credentialing processes, educational innovations, development of public health policy, enhanced access to care, reconfiguration of the dental workforce and scope of practice, and, yes, advances in science. A variety of dental schools will be required to address all of these challenges. We should do this together. Collaboration now is essential.
Of particular interest is the potential benefit of regional and national collaborations between research-intensive and clinical education-intensive institutions to ensure that the entire enterprise achieves appropriate balance and appropriate emphasis on science.4 There are currently existing examples of highly successful regional consortia designed specifically to share scientific expertise in the development of future generations of scientists.
The Hollies sang a song in the late 60s entitled "He Ain't Heavy, He's My Brother." That is what we are reminded of when thinking about this entire pseudo-debate. The message is, let's lift each other up and develop constructive solutions to the real issues facing dental education. Let's not create confusion and distraction by continuing an apparent mismanaged agreement. Let's stay off the Road to Abilene! It is a hot, dirty, wasteful, and inherently dissatisfying trip.
1. Wartman SA. The compelling value proposition of academic health centers. Association of Academic Health Centers: www.ashcdc.org/policy/reddot/AAHC_ValueProposition.pdf. Accessed October 12, 2010.
3. Pinn VW, Clayton JA, Begg L, Sass SE. Public partnerships for a vision for women's health in 2020. J Women's Health. 2010;19(9),1603-1607.
4. Pyle MA. Fast-forward frive years: has dental education changed? J Amer Coll Dent. 2010; 77(2), 34-39."