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J Dent Educ. 71(2): 217-221 2007
© 2007 American Dental Education Association
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Critical Issues in Dental Education

Addressing the Marketplace Mentality and Improving Professionalism in Dental Education: Response to Richard Masella’s "Renewing Professionalism in Dental Education"

Ronald W. Botto, Ph.D.

Key words: professionalism, ethics, hidden curriculum, productivity, white coat ceremony, honor code, teaching professionalism, teaching ethics, dental education


   Abstract
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 Abstract
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Richard Masella has written a very thought-provoking article that makes many excellent arguments regarding critical issues about professionalism in dental education. Rather than focus on minor points of contention, this response to his article highlights two main areas for further discussion. The first is the impact of the "marketplace" mentality and how there needs to be a balance between fiscal responsibility and ethical and professional responsibility. Changes in language are suggested as a starting point. Instead of using the term "productivity" to describe the goal, we need to focus on the process of behaving ethically, effectively, and efficiently in the provision of care to patients as well as in general professional behavior. The second major emphasis is on recommendations for improving the ethical climate of the dental college community and the teaching, exhibition, and celebration of professionalism. Included in this area are discussions of white coat ceremonies and honor codes, as well as the importance of recognizing the impact of the hidden curriculum in dental ethical education. Masella has made a major contribution by bringing forth strong arguments for discussing whether dental education truly is committed to teaching professionalism in a way that has meaning and impact rather than simply complying with accreditation standards. While there are certainly several points that appear to be speculative and could be debated in Masella’s article, he has provided a valuable catalyst for discussion and introspection by identifying critical issues for both dental education and organized dentistry to address.

Richard Masella’s thoughts on professionalism in dental education are both broad-ranging and thought-provoking.1 While I may take issue with some of his views (for example, the influence of the decline of religious prominence on the ethics of today’s students or the predictability of unethical behavior), the majority of his arguments are on target from my perspective and critical to dental education. The issue of professionalism is timely and essential, but elusive. As so well stated in his opening comments, "concern for professionalism should be at the heart of dental education and lifelong practice." While it is doubtful that there is much disagreement with this point of view, Masella points out we need to be more effective in addressing this issue.

Since space limitations restrict comment on every point, the focus of this response will be on two main areas that Masella addresses: his points regarding the role of the "market environment" and recommendations for improving professionalism in dental education.

The issue of the market environment is, indeed, problematic in many areas of health professions education and other types of professional training as well as in dental education, often because of the costs associated with providing the education.2–6 As a result, there is no doubt that higher education has become more business-oriented than in the past and students have developed a more consumer-oriented focus of making sure they are getting what they perceive as value for their tuition dollars. The competition for admission to colleges (and dental schools) is greater than ever. However, an unwillingness by the public and political establishments to spend the money necessary to support higher education appropriately continues to create economic concerns, including the increase in tuition and resultant student debt.2,4,6

While we could portray this shift in focus as saying "Goodbye [to] Mr. Chips" and hello to "Show Me the Money," that represents two extreme positions that do not accurately reflect where education is today (except, perhaps, on more cynical days). The problem is that, with greatly reduced public funding of education, there is greater emphasis on the need to "balance the books." Dental education has always been an expensive proposition. While in the past, universities may have been willing to underwrite the losses associated with having dental schools, that is no longer the case—which led to many of the dental school closings in the past twenty years.7 Dental school deans are being held accountable for their budgets, and university presidents and chancellors can go only so far in their willingness to allow a dental school to operate in the red. The problem is finding the middle ground between the "Goodbye, Mr. Chips" and "Show Me the Money" mentalities. Unfortunately, the current emphasis on "productivity" in dental education gives the impression that we are more interested in seeing the money than in how it was produced. I do not think that impression is accurate, but nonetheless, it is present. Deans have fiscal responsibilities that they must meet. The challenge is how to meet the responsibility without sacrificing the quality of education and, most importantly, professionalism.

The first step that I believe must be taken to address the perception is a change in the language we use. The term "productivity" is the primary culprit. The emphasis of the term is rate of production per student and the associated income for the school generated by each student or resident, rather than the quality of health care services provided or the well-being of the patient. The emphasis on production is not intended to de-emphasize concern for the quality of clinical services or a lack of attention to the patient’s health status, but that is the underlying connotation when so much attention is devoted to how much money students and residents generate as a consequence of their patient care activities. As Masella and others point out, this translates into concerns regarding commercialism in private practice.8,9

I would like to suggest that we recognize that while a dental school cannot operate at a loss, just as in private practice, we need to explicitly state that not doing so is not at the expense of quality of care or professionalism. We need to change our terminology to emphasize student ethicality and effectiveness as well as efficiency. We can teach the student that being ethical includes addressing the patient’s needs compassionately and competently, yet in a manner that incorporates time management principles so that the patient, student, staff, and faculty are making the best use of everyone’s time. Being ethical, caring, and cost-effective can all occur simultaneously. Talking about being ethical, effective, and efficient will hopefully take professionalism out of the "footnote status" that seems to be implied by the emphasis on productivity.

A strong message in Masella’s article and many others on ethics in recent years is that the so-called "hidden curriculum" exerts a powerful influence on students.10–17 As pointed out, it refers to the "informal curriculum"—that which is practiced rather than, or in conformance with, that which is formally taught in lecture, and it therefore, can be negative or positive.10–12,18–20 The message is the old axiom of "actions speak louder than words." The medical education literature has clearly shown that students mimic faculty behavior in their treatment of patients as well as in their own personal conduct. Thus, they will behave either according to or in spite of theoretical or "best practice" standards communicated during lectures. The clear message to faculty is "practice what you preach" because it is your own practice that influences student conduct.

The same message has to be listened to very carefully by all members of the dental school: students, staff, and administration, as well as faculty. When students observe classmates cheating, they are more likely to cheat.20 When students observe other members of the school not adhering to high professional standards, they are more likely to act accordingly.

The same principle holds true when faculty, administration, and staff observe each other. For example, the current emphasis on research dollars being brought in by faculty sends the same message that clinical productivity sends to students and staff. I frequently hear that dental schools aspire to be among the top schools in the nation, which they then measure by research or clinic income; but I have yet to hear of any school touting that it either wishes to be, or is, among the top schools in the nation in professionalism and ethical behavior. We do hear the message that status is measured by research dollars, board scores, and DAT and GPA scores. The "hidden curriculum" message is not professionalism, but productivity. Fiscal responsibility is critical to survival, but let’s simultaneously state that it is both ethical responsibility and fiscal responsibility that we value and measure.

The second point I wish to make involves recommendations regarding how ethics should be taught, both formally and informally. Again, while I may have some points of disagreement with Masella, I do agree with much of what he says. Let me make clear that I believe that ethics can be taught.22 The question is not can ethics be learned, but can ethical behavior be practiced. Our recent debates in the JDE notwithstanding,22–25 we all agree that we are not always teaching ethics in the most effective fashion.26 Traditional lectures are of minimal value other than perhaps meeting accreditation standards. The move to white coat ceremonies in dental education could be a step in the right direction,27 but, as Masella states via Stern, "professionalism is not something that students and practitioners can put on and take off, like a white coat. It exists deeply as part of personal identity." The problem as pointed out by Bebeau and others is that white coat ceremonies tend to be more a "rite de passage" than substantive or meaningful in an ongoing way in day-to-day activities.13,28–30 They are often held when students first enter dental school or the clinic to mark their passage into the professional aspects of their careers, but often come with little, if any, educational or developmental emphasis.29,30 The establishment of honor codes can also have a positive effect;31–37 however, they too can have negative aspects and must be integrated with other efforts to be effective.38,39 Similarly, ethics courses that are predominantly lecture-based and isolated from the rest of the curriculum do little in terms of influencing behavior.23 Ethical health is similar to oral health: knowledge is necessary, but not sufficient. The individual needs to be able to display the behavior, and it needs to be part of his or her daily repertoire, i.e., a daily habit rather than an exception displayed when deemed necessary. It is this inculcation of knowledge as well as allowing and encouraging its display that is both critical and difficult.

I would like to offer the following suggestions:

  1. Teach ethics courses in every year of the curriculum, and integrate them into "non-ethics" courses as well. For example, when developing a treatment plan, discuss the ethical issues involved (patient autonomy, compassion, competence, etc.) along with the proposed treatment.
  2. Have the ethics courses involve both lecture and group discussion of cases using methods of moral reasoning. In addition, have a variety of faculty from all disciplines and administrators facilitate the discussion groups. Vary the faculty annually so that ultimately all faculty and administrators participate in a recurring fashion. Find ways to include staff in the courses and discussions.
  3. Integrate ethics into case presentations, clinical portfolios, and daily clinical feedback to students. Have group discussions of the reflections evidenced in the portfolios.
  4. Train faculty to be sensitive to the daily ethical issues that students deal with, as well as to their own behavioral influence on students. Have ethics be part of the faculty’s daily lives as well.
  5. Create a community that values professionalism for all, including staff, administration, students, and faculty. This is accomplished through collaborative efforts that develop an institutional set of beliefs that are professed and practiced regularly. This is achieved through the collective development of codes of ethics by and for students, administration, faculty, and staff. The respective codes need some commonality as well as differences that reflect the needs as well as uniqueness of the specific groups. In addition, have an honor code that is regularly advocated, acknowledged, and subscribed to.
  6. Celebrate professionalism. Praise its behavior by all, not just the "best." Acknowledge it and refer to it as much as achievement in other areas. Display the college’s ethical values, codes, and beliefs for all to see and as constant reminders of the commitment by each member of the dental school community.
  7. Value the achievement of professionalism as much as research dollars generated, board scores achieved, and clinical procedures accomplished.
  8. Change language that is commonly used to create a shift in emphasis and meaning. Use the terms "ethicality," "effectiveness," and "efficiency" instead of "productivity." This includes focusing on the process of behaving and treating patients ethically, effectively, and efficiently instead of focusing on the end result of increased productivity. This also means getting students to stop calling someone who reports unethical behavior a "snitch" and, instead, referring to them as someone with "high ethical standards."
  9. Address the stress issues that tempt students to violate standards of professionalism. If we do not make allowances for not achieving passing grades honorably, then we will have students achieving them dishonorably. Just as important is addressing the competitive drive among students to be #1 in the class. In addition, teach students to manage stress so they don’t give in to it. Do the same for faculty, staff, and administrators.
  10. Emphasize the personal prevention of unethical behavior rather than just focusing on its punishment. If we had better mechanisms to prevent unethical behavior, then we wouldn’t have to worry as much about dealing with failures. By "personal prevention" I mean emphasis on personal responsibility to avoid unprofessional behavior rather than just policing to prevent it. Policing tends to emphasize not getting caught more than behaving ethically. It also tends to work primarily through external means, rather than through a set of internalized beliefs and values.
  11. Make the consequences of unethical behavior as remedial as possible. This does not just mean having the violator take another course in ethics. Although it is possible that the individual was not aware of engaging in unethical behavior, in most cases he or she was aware that the behavior was unethical. Remediation needs to focus on what it was that led that individual to succumb to the temptation to behave unethically. Additionally, remediation should include rehearsal of what the individual can do differently. Assist violators in recognizing and desiring the benefits of behaving ethically. This means the focus needs to be on personal insight and growth (what is typically called therapy), rather than just another course.
  12. Encourage and direct moral development so that rather than seeing self-interest and altruism as being in conflict, they are seen to be synonymous.
  13. Have professionalism truly become a part of lifelong learning. Encourage organized dentistry to make ethics part of annual CE requirements for practitioners.
  14. Have white coat ceremonies be more than just symbolic exercises performed for new students. Have them follow successful training in professionalism. Repeat the ceremony annually with a reaffirmation of professionalism, and have all members of the dental college community (students, staff, faculty, and administrators) participate in the annual reaffirmation.
  15. Teach professionalism as we teach restorative dentistry (ubiquitously) and value professionalism as much as NIDCR and NIH grants.

As Masella has pointed out in his thought-provoking essay, morality and professionalism are dynamic and, therefore, open to change. It is the responsibility of all of us to make sure both of these foundations of dental education and dental practice grow in a positive direction.


   Acknowledgments
 
I would like to thank Dr. Anne Koerber and Dr. Patricia Nihill, of the University of Illinois at Chicago College of Dentistry, and Ms. Deirdre Shires, of the University of Illinois at Chicago College of Public Health, for their assistance with this article.


   Footnotes
 
Dr. Botto is an Associate Professor and Director of Clinical Behavioral Sciences, Division of Behavioral Sciences, Department of Pediatric Dentistry, University of Illinois at Chicago College of Dentistry. Direct correspondence to him at Department of Pediatric Dentistry, University of Illinois at Chicago College of Dentistry, 801 S. Paulina (MC 850), Chicago, IL 60612; 312-314-5929 phone; 312-996-1981 fax; rbotto{at}uic.edu.


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