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The Relationship Between Gender and Postgraduate Aspirations Among First- and Fourth-Year Students at Public Dental Schools: A Longitudinal Analysis

Key words: dental education, graduate, dental practice patterns, gender

Submitted for publication 12/18/06; accepted 03/30/07

	Abstract

Top Abstract Methods Results Summary and Discussion References

 
The purpose of this study was to examine gender differences and other predictors of postgraduate plans among U.S. dental students. A national sample of dental students was surveyed in their first and fourth years of dental school. Female first-year students were less likely than male students to express interest in specialization in endodontics and oral surgery. Fourth-year students who had a dental school mentor, a high GPA, and encouragement from significant others were more likely to apply for postgraduate training. Gender and first-year interest in dental specialization did not affect the likelihood of applying for postgraduate training in the fourth year. Female fourth-year students were more likely to predict that they would be an associate in a practice five years following graduation. The results suggest that mentoring and faculty encouragement are important influences on dental students’ plans for postgraduate education.

The consequences of the influx of women into dentistry and their practice patterns have not been extensively studied, compared to the entry of women into other professions. Niessen has suggested that "the private practice of dentistry may provide an ideal laboratory for examining how women can integrate family and career. As the owner of one’s practice, a woman can set the rules to meet her needs."⁵

Research on career decision making among health professionals shows that maintaining an appropriate balance between work and family life over the course of one’s career is a major concern for both men and women, and those concerns affect decisions regarding specialization and postgraduate education. Scarbecz and Ross⁶ found that both male and female first-year dental students rated the flexibility of a dental career (in terms of the ability to balance work and family) as an important motivation for choosing the dental profession. A study of British dental students by Stewart et al.⁷ found that 90 percent of women and 70 percent of men anticipated taking career breaks because of childcare duties. Lawrence et al.⁸ found that women physicians in New Zealand rated flexibility as an important influence in their choice of medical specialization and that women cited lack of compatibility with family life as a deterrent to specialization in demanding disciplines with long and unpredictable work hours. Similarly, other studies^9–11 have shown that lifestyle concerns and long work hours were deterrents among medical students to pursuing surgical specialties.

Dentistry is unique among health care professions in that the majority of dentists are independent health care providers: 76 percent of practicing dentists in the United States are in solo practice.¹² Only 60 percent of U.S. physicians are in office-based practices, and, of those, only 28 percent are in solo practice.¹³ U.S. dentists have managed to maintain much of their autonomy in the clinical setting, compared to the relative decline in autonomy for physicians.¹⁴ Compared to dentists in other practice arrangements, solo practitioners and partners are more likely to report that they have control over their work environment, and control of work environment among dentists is associated with higher levels of job satisfaction.¹⁵ Dental students also rate solo ownership as the preferred practice arrangement, although women rate employee practice arrangements (defined as "working for the owner dentist . . . with . . . minimal, if any, involvement in business decisions") more favorably than do men.¹⁶

Women (and men) who are not owners of their practice may have less professional autonomy and may be less able to experiment with different approaches for integrating family and career. In 1999, women made up only 6.8 percent of all solo dentists in the United States.¹² This is partly a function of differences in the age distribution of male and female dentists. More experienced dentists have had the time and opportunity to establish solo practices, and the mean age of male dentists in the United States is 49.8 years while the mean age of female dentists is 39.9 years.¹² However, even among dentists who graduated in the last ten years, women make up only 27.3 percent of new solo dentists, which is less than what would be expected given the increasing number of women graduating from dental schools.¹⁷

Dental specialization also has rewards, and dental specialists earn substantially higher incomes than general dentists do.¹² However, much like the general profession, practitioners in dental specialty fields are still overwhelmingly male. In 2004, women made up 15 percent of the members of the American Academy of Periodontology and 12 percent of the members of both the American College of Prosthodontists and the American Association of Orthodontists.^18–20 Women made up 35 percent of the members of the American Academy of Pediatric Dentistry in 2004. However, the number of women entering pediatric residency programs in 2004 exceeded the number of men.²¹

Against this backdrop of the desire for career flexibility and the importance of postgraduate education and practice ownership as routes to professional and personal autonomy for dentists, the purpose of this study was to examine gender differences in postgraduate plans among U.S. dental students using data from a national longitudinal sample of dental students.

The first part of this article examines students’ plans for postgraduate education. Specifically, the goals are, first, to examine gender differences in postgraduate educational plans among both first-year and fourth-year dental students and, second, to examine the combined effects of initial motives for pursuing a dental career, initial (first-year) postgraduate educational aspirations, and the effects of the dental school experience on fourth-year students’ educational plans.

The second part of this article examines fourth-year students’ plans regarding postgraduate practice arrangements. Practice arrangements refer to students’ assessment of the likelihood that they will be self-employed in a solo or partnered practice or an associate in a larger dental practice following graduation from dental school. Thus, the goals are, first, to examine gender differences in practice arrangement plans among fourth-year dental students and, second, to examine the combined effects of initial motives for pursuing a dental career and the effects of the dental school experience on fourth-year students’ practice plans.

To date, the most comprehensive studies of dental school students are based on data from the American Dental Education Association (ADEA) annual survey of graduating dental school seniors.^22,23 However, our study differs from the annual ADEA survey studies. We used longitudinal data to examine how students’ postgraduate aspirations change over the course of their dental school careers. We also examined additional factors that may affect postgraduate plans above and beyond those examined in the ADEA surveys.

	Methods

Top Abstract Methods Results Summary and Discussion References

 
Data Collection
Data on first-year and fourth-year dental students were collected via self-administered questionnaires. The questionnaires and research methodology for the study were reviewed and approved by the University of Tennessee Health Science Center Institutional Review Board (IRB), as well as the institutional review boards of dental schools whose students participated in the study.

During the 2000–01 academic year, we relied on professional contacts from colleagues at our home institution to build a sample of dental schools for our study. We contacted dental school administrators and asked if they would be willing to survey their first-year students. A random sample of dental schools would have been ideal. However, we reasoned that a random sample was unlikely to be successful, given the logistical difficulties of questionnaire distribution for dental school administrators and the varying Institutional Review Board requirements of each institution. Institutions were assured that they would not be identified in research reports, nor would data from individual institutions be singled out in research reports. Nine publicly funded dental schools across the country participated. The sampled dental schools had a mean class size of sixty-five students and were geographically diverse, with each major region of the United States represented. We also collected identifying information from all surveyed students. To protect students’ confidentiality, identifying information was maintained in a physically separate location from the physical and electronic questionnaire data. We sent out 582 surveys, and 430 first-year dental students completed the survey for a response rate of 74 percent.

In academic year 2003–04, a follow-up survey of these students as fourth-year students was conducted. Of the original nine dental schools that participated in 2000–01, one school did not respond, but the remaining eight initially agreed to participate in the fourth-year survey. Two of the eight schools failed to return any surveys. Six schools contributed a total of 172 surveys. Of these, 138 were from previously surveyed students. An additional thirty-four surveys were returned from students who had not participated in the first-year survey. The overall response rate from the six participating schools on the fourth-year survey was 41 percent, and 32 percent of the original 430 students participated in the fourth-year follow-up. We used the identifying information gathered in the first-year survey to match fourth-year data with first-year survey data.

Questionnaire Design
First-Year Questionnaire.
The survey instrument was a four-page (single-sided), self-administered questionnaire. Demographic variables on the questionnaire included race, gender, family structure as an adolescent, and parents’ education. Previous research has identified these variables as correlates of educational ambition and attainment.^24,25 Questions about plans after dental school were modeled after questions from the annual ADEA survey of dental school seniors.²⁶

A list of motives for attending dental school was compiled from the motives listed in previous literature^27–31 and from discussions with our dental school admissions officer. We constructed additional questions, based on the second author’s participation in several hundred unstructured interviews with dental school candidates as a member of the dental school admissions committee. Duplicate questions were eliminated from the list, and questions were reworded to be consistent with an ordinal response scale. Students were asked to rate the importance of each motive (reason) for attending dental school using a five-point scale, with 5 indicating "Very important" and 1 indicating "Not at all important." The final version of the questionnaire contained thirty motive questions. Question wording is reported elsewhere.⁶

We also asked first-year students about their postgraduate aspirations. We asked them to rate their interest in dental specialty areas, and we also asked about their postgraduate career plans one year after graduation, including a variety of potential practice arrangements, government service, dental education, and volunteer work.

Fourth-Year Questionnaire.
The fourth-year survey instrument was also a four-page (single-sided), self-administered questionnaire. Some portions of the questionnaire replicated the first-year survey. Students were asked a series of demographic questions and were asked to rate themselves on motives for attending dental school. Students were also asked whether they had applied for a postgraduate residency and about their expectations regarding practice arrangements one year and five years following graduation from dental school. Lee found that the influence of significant others is especially important for women when they consider careers in science and technology.^32,33 For this reason, students were asked whether family members, friends, or dental faculty had encouraged them or were supportive of their pursuit of postgraduate education in dentistry.

Prior to distribution to dental schools, the fourth-year questionnaire was pilot-tested on a convenience sample of fourth-year dental students at our home institution. The pilot test did not reveal any significant problems in question wording or questionnaire design, though some students said that the questionnaire was lengthy.

Plan of Analysis
First, we examined basic demographic trends in the survey data and compared these trends to data from the annual ADEA survey of 2004 dental school seniors. Second, we examined first-year dental students’ interest in dental specialty areas. We also examined the effect of gender and several other first-year demographic variables on postgraduate educational aspirations. Third, we examined fourth-year dental students’ plans for postgraduate education, and, for students not planning on postgraduate education, we examined practice arrangement plans for students one year after graduation. We also examined practice arrangement plans for all students five years after graduation.

The primary method of analysis we used was binary logistic regression, whereby the dependent variable is a binary outcome and the effects of independent variables on the odds of a given outcome are assessed. Thus, we examined factors that increased or decreased the odds of pursuing postgraduate education, expectations of being self-employed (solo or partnered practice) following graduation, and expectations of being an associate (employee) of a larger practice following graduation. We used bivariate logistic regression to look at the effects of individual independent variables on postgraduate plans. We used multivariate logistic regression to examine the combined effects of multiple independent variables: gender, demographic variables, first-year aspirations, the influence of significant others, and students’ dental school experiences on students’ postgraduate plans.

All analyses were conducted using Statistical Package for the Social Sciences for Windows, Release 14.0 (SPSS, Chicago, IL) statistical software. P values .05 are considered to be statistically significant.

	Results

Top Abstract Methods Results Summary and Discussion References

 
Table 1 compares first- and fourth-year survey respondents on selected demographic characteristics and compares survey respondents to respondents to the 2004 ADEA survey of dental school seniors.²³ Although our survey samples are not probability samples of the U.S. dental student population, both the first- and fourth-year survey samples mirror some of the overall characteristics of the dental school class from which they were drawn. The percentage of female respondents in the survey sample is similar to the ADEA sample. Parental educational background in our survey sample (not asked in the fourth-year survey) is similar to parental educational background in the ADEA sample. Similar percentages of fourth-year respondents and ADEA respondents have applied to an advanced education program, and, as in the ADEA survey, the percentage of women who have applied to an advanced education program is higher than the percentage of men who have done so. Approximately 40 percent of respondents in our fourth-year survey have $100,000 or more of debt compared to 59 percent in the national sample. Additionally, 46.8 percent of fourth-year survey respondents were married or living with a partner, and 16.1 percent of respondents had children.

We were concerned that fourth-year respondents were different from fourth-year nonresponders. For that reason, we compared fourth-year survey respondents to fourth-year nonresponders on their first-year responses to variables regarding interest in dental specialization and practice arrangements. There were no statistically significant differences between fourth-year respondents and nonresponders to first-year survey questions regarding postgraduate practice aspirations or level of interest in dental specialty areas. The results of this analysis are presented in Table 2.

Table 3 presents the odds ratios for first-year dental students having high interest in each dental specialty area. The baseline category for gender is males, and the baseline category for race is white. Odds ratios greater than 1.0 indicate that females or nonwhites have greater odds or likelihood of reporting high interest compared to their respective baseline categories. Odds ratios less than 1.0 indicate that females or nonwhites have lower odds or likelihood of reporting high interest compared to their respective baseline categories.

There were few race differences in interest areas. Nonwhite first-year students (students who identified themselves as Native American or Alaska Native, Asian or Pacific Islander, Black/African American, Hispanic or Latino, and Other) were significantly more likely than white students to express high interest in attending an AEGD program following graduation. Nonwhite students were less likely than white students to express a high interest in dental specialization overall; this coefficient approached statistical significance (p=.063).

We used multivariate logistic regression to examine the combined effect of several independent variables on the odds of high interest in dental specialization (analysis not shown). The independent variables entered into each logistic regression equation were race (white v. nonwhite), gender, marital status, whether students had children, and parents’ education. Four scales measuring specific categories of motives for attending dental school were also included as independent variables. Previous research⁶ using this sample data showed that dental students’ motives for pursuing a career in dentistry were organized around four principal factors: 1) a MONEY factor, emphasizing the financial rewards associated with a dental career; 2) a PEOPLE factor, focusing on the caring/helping people aspect of dentistry; 3) a FLEXIBILITY factor, emphasizing the attractiveness of dentists’ flexible schedules; and 4) a BUSINESS factor, centering on the attractiveness of being self-employed or one’s own boss.

The significance and direction of the gender and race effects shown in Table 3 were unchanged after controlling for the effects of these other variables. Female first-year dental students were still less likely than males to express high interest in endodontics and oral surgery and more likely than male dental students to express high interest in pediatric dentistry and AEGD programs.

Fourth-Year Students’ Plans for Postgraduate Education
Fourth-year students were asked whether they had applied to a postgraduate specialty education program. Table 4 presents the bivariate relationships among several demographic factors and the odds or likelihood of applying to a postgraduate program. For each independent variable examined, the baseline category is designated with an odds ratio of 1.00. Odds ratios greater than 1.00 indicate that a group has greater odds or likelihood of applying for a postgraduate specialty education program compared to its respective baseline category. Odds ratios less than 1.0 indicate that a group has a lower likelihood of applying for a postgraduate specialty education program compared to its respective baseline category.

Interpersonal variables appeared to have the greatest impact on whether fourth-year students applied to a postgraduate educational program. The odds of applying for students who had a dental school mentor—defined on the questionnaire as "someone on the faculty who helped you develop professionally as a dentist with whom you worked closely"—were 2.31 times greater than the odds for students who did not have a mentor.

We also asked students if other people had encouraged them to pursue postgraduate education. For each group of significant others—spouse or significant other; other family members; dental school mentor; close friends; dental school faculty—students were asked to rate the level of encouragement or support received on a five-point scale with 5 indicating "Have encouraged me very much" and 1 indicating "Have not encouraged me at all." Students who rated the level of encouragement as 4 or 5 were classified as having received a high level of encouragement from a particular person/group. For each group of significant others from which high encouragement was received (spouse, family members, dental school mentors, friends, and dental school faculty members), the odds or likelihood of applying for postgraduate education was significantly higher than the odds for students who received less encouragement. The odds of applying for students who reported receiving a high level of encouragement from faculty were 5.93 times greater than the odds for students who reported receiving less encouragement. High encouragement from a mentor increased the odds of applying by 2.50, and high encouragement from a spouse increased the odds of applying by 3.43.

Students who had a high GPA—defined as being above the sample median of 3.40—also had increased odds of applying for postgraduate education.

Table 5 presents the results of a multivariate logistic analysis of the fourth-year data with application to postgraduate education as the dependent variable. The purpose of the multivariate analysis was to determine if the bivariate predictors of application for postgraduate education presented in Table 4 were still statistically significant, even after controlling for the effects of additional independent variables. Model I examines the combined effect of multiple demographic variables on the odds of fourth-year students applying for postgraduate education. Model II adds aspects of students’ dental school experience to the equation: whether students had a mentor, whether they had a high dental school GPA, and whether they received a high level of encouragement to pursue postgraduate education from significant others. Model III is a longitudinal model that adds variables from the first-year student data, including whether students reported a high level of interest in postgraduate education during their first year, as well as the four first-year motive scales for attending dental school. The motive scales had scores ranging from 1 to 5, with higher scores indicating that students placed greater importance on a particular set of motives for attending dental school.

The direction of the effects of other variables replicated some of the results of the bivariate analysis in Table 4. Having a high GPA and reporting high levels of encouragement from faculty increased the odds of applying for postgraduate education for students in our sample. Having greater than $100,000 in student debt also increased the odds of applying for postgraduate education in the multivariate model.

In Model III, students who expressed an initial interest in postgraduate education in the first year of dental school did not have increased odds of applying for postgraduate education in their fourth year. With the exception of the MONEY scale, initial (first-year) motives for dental school did not affect the odds of applying in the fourth year. The odds of applying for postgraduate education increased as the importance of money as a motive for attending dental school increased.

Predictors of Fourth-Year Students’ Expected Practice Arrangements
Fourth-year students were asked to estimate the likelihood of their being in a solo or partnered practice (i.e., self-employed) or being in an associate practice one year after graduation. Students were asked to estimate the likelihood of being in a particular practice arrangement one year after graduation, with 5 indicating "Very likely" and 1 indicating "Not at all likely." Table 6 presents the bivariate relationships among several demographic factors and the odds or likelihood of reporting that a particular practice arrangement is "very likely" (4 or 5 on a five-point scale) one year after graduation. The analysis is limited to fourth-year students who had not applied for postgraduate dental education.

We asked all fourth-year students to predict their practice arrangements five years after dental school. In separate questions, students were asked to estimate the likelihood of their being in a solo practice, a partner in a practice, or an associate in a larger practice. Virtually all students predicted a high likelihood (4 or 5 on a five-point scale) of being self-employed (solo or partnered practice) five years after graduation. There was greater variation in students’ estimation of the likelihood of being an associate in a larger practice five years after graduation. Table 7 presents the odds or likelihood of predicting an associateship (4 or 5 on a five-point scale) five years after graduation by several demographic variables for all students in the fourth-year sample.

Table 8 presents the results of a series of multivariate logistic regression models with high likelihood of associate employment five years after graduation as the dependent variable. The purpose of these analyses was to assess whether the statistically significant bivariate relationships among gender, race, and the prediction of associate employment shown in Table 7 remained statistically significant even after controlling for the effects of other independent variables.

The effects of gender on the likelihood of predicting associate employment five years after dental school remained statistically significant and are consistent with the unadjusted (bivariate) odds ratio presented in Table 7. Even after controlling for the effects of other variables, the odds of fourth-year women predicting associate employment for themselves five years after graduation were significantly higher than the odds for men. However, the effect of race was no longer statistically significant.

Consistent with the bivariate analysis, students who had applied for postgraduate education were more likely to predict associate employment for themselves five years after dental school than were students who planned to go directly into practice after dental school. Last, students’ initial motives for attending dental school had no effect on their fourth-year prediction of practice arrangements following dental school.

	Summary and Discussion

Top Abstract Methods Results Summary and Discussion References

 
To the best of our knowledge, this is the first study to systematically examine gender differences in aspirations for advanced dental education and practice arrangements using a multi-institution longitudinal U.S. sample of dental students.

The analysis revealed that, even at an early stage of students’ dental careers, gender plays a significant role in the level of interest in dental specialty areas. Female first-year dental students were less interested in some dental specialties than their male counterparts, specifically oral surgery and endodontics. Female first-year dental students were more interested in pediatric dentistry than were male students. These were robust effects that persisted even after controlling for other demographic and motive variables. Thus, even with a limited knowledge of dental specialty areas and their own interests, first-year women expressed less interest in some specialty areas than did men.

Our analysis showed that, by the fourth year of dental school, gender differences in postgraduate education plans had disappeared. We view this as an important indication that students’ ascribed characteristics are largely irrelevant to their dental school experience and their potential level of educational attainment in dentistry. First-year students’ interests in dental specialization were also not predictive of whether students actually applied for postgraduate education in their fourth year. For fourth-year students, the strongest predictors of postgraduate educational plans were mentoring and encouragement from significant others including family members and dental school faculty. Even though some of these relationships were weakened in multivariate analyses, the results point to the importance of mentoring and encouragement of students during their years in dental school to the development of their postgraduate educational plans.

Among fourth-year students not applying for postgraduate education, both male and female students were about equally likely to see themselves as independent or partnered practitioners following dental school. As noted above, being a self-employed health professional is a characteristic that is relatively unique to the dental profession in contrast to practice patterns of physicians. Thus, the practice model for dentists, and the practice model that most students were likely to witness during dental visits prior to dental school, is the (predominantly male) dentist as sole proprietor. Additionally, part-time and volunteer faculty made up 43.5 percent and 15.2 percent, respectively, of all U.S. dental school faculty in 2004–05.³⁴ These faculty are likely to be engaged in private practice and are likely to strongly endorse the self-employed practice model and serve as influential role models for dental students during their clinical training.

However, female fourth-year dental students were more likely than male dental students to predict a high likelihood of being an associate in a dental practice five years after graduation. Women’s greater expectations of being an associate may be related to expectations about the demands of childbearing and childrearing at that point in their careers, although we have no data to directly test this hypothesis. Among dentists in private practice, women are more likely to work part-time than men,³⁵ and women may view employee or associate positions as being more amenable to part-time work.

In the first-year survey, both female and male dental students rated flexibility as an important motive for attending dental school.⁶ That is, first-year students reported that an important reason for choosing a dental career was that they viewed dentistry as providing flexible hours and sufficient family time. However, according to a 1995 ADA survey, female dentists spent about double the amount of time in childcare and housework compared to their male colleagues,³⁶ adding what amounts to a substantial second shift of work to their lives.³⁷ Women were also more likely than men to take a leave of absence from work for childrearing and to take longer leaves of absence for that purpose.³⁶ Thus, the expectation of fourth-year women that they are likely to be in an associate position five years after graduation is perhaps an expectation that they will have to scale back their careers at some point in the future to balance the demands of family and work. These students may not see the independent practice as the ideal laboratory for balancing work and family as envisioned by Niessen.⁵

The expectation of fourth-year women that they are likely to be in an associate position five years after graduation may also be an expression of a preference among female students for minimal financial risk and the increased income security of a guaranteed salary.¹⁶ In our sample data, female first-year dental students rated self-employment as a less important motive for pursuing a dental career than did male first-year students.⁶ However, in the present study, this BUSINESS motive was unrelated to the odds of fourth-year students predicting that they would be an associate five years after graduation. In multivariate analysis, even after controlling for initial motives for pursuing dentistry, fourth-year women were still more likely than men to predict an associate position for themselves.

There are several limitations to our study. First, our study was not based on a random sample of U.S. dental schools, which may limit the generalizability of the results. Second, although our study was a longitudinal panel study, reports of fourth-year dental students regarding mentoring and encouragement from others were still retrospective self-reports of their dental school experiences. Further, although there is no evidence that fourth-year respondents differed substantially from nonresponders, the low response rate among fourth-year students reduced the power of our statistical analysis. Estimates of many coefficients did not reach statistical significance, even when the apparent effect sizes were large.

Despite these limitations, our results suggest that the dental school experience, in terms of mentoring and encouragement from faculty, is likely to be an important influence on students’ postgraduate educational plans, independent of the effects of demographic variables and even students’ initial interests or perceptions upon entry into dental school. A report issued by ADEA suggested that mentoring was important for the development and retention of dental school faculty.³⁸ The report suggested that mentoring supported the growth and professional development of young dental professionals and provided opportunities to clarify goals, values, and professional choices. It seems likely that mentoring plays no less a role in dental education. Fruitful directions for future research might include more systematic studies of the influence of mentoring on dental students or the development of pilot programs in dental education to ensure that students have mentors to whom they can turn for encouragement, support, and advice during their dental school experience.

Dental professionals, as full- or part-time faculty in dental schools, in their private practices, or via professional dental organizations, can be potential mentors to younger colleagues. Young dentists and dental students, regardless of gender, are likely to benefit from the experience of having mentors, in terms of professional growth, a greater awareness of career opportunities, success in their chosen profession, and the provision of improved care.

	Footnotes

 
Dr. Scarbecz is Associate Professor, Department of Pediatric Dentistry and Community Oral Health; and Dr. Ross is Associate Professor, Department of Restorative Dentistry—both at the University of Tennessee College of Dentistry. Direct correspondence and requests for reprints to Dr. Mark Scarbecz, University of Tennessee College of Dentistry, 875 Union Ave., Memphis, TN 38163; 901-448-1211 phone; 901-448-1294 fax; mscarbecz{at}utmem.edu.

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