J Dent Educ. 72(2_suppl): 25-27 2008
© 2008 American Dental Education Association
New Models of Dental Education: The Macy Study Convocation |
Implications of Moving to a Patient-Centered Model in Clinical Dental Education: Reactions to "Financing Dental Education: The Findings of the Macy Study"
Three sessions at the April 2007 Macy study convocation were devoted to reactions from learned colleagues to the presentations on "Financing Dental Education" by Dr. Howard Bailit and Dr. Allan Formicola.1–3 Summaries of those reactions are presented here.
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Dental Education in Contrast with Other Health Professions
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Dr. Carole A. Anderson, vice provost and interim dean, The Ohio State University College of Dentistry, agreed that dental school-based clinics are not patient-centered and that they should be. Based on her experience as a high-level administrator in health sciences education and former nursing school dean, she described her surprise at discovering during her early days as interim dental school dean that dental clinics close to accommodate faculty and student vacation and meeting schedules. This practice is in contrast to hospital clinics, which stay open year-round to treat patients and generate revenue. She said she also found that dental faculty salaries were low compared to other disciplines on campus, that the different dental clinics function as distinct "silos," and that only the faculty practice clinics make money. "Dentistry is on a collision course," she cautioned, referring to academic dental institutions’ financial challenges, increases in tuition, disparity between academic and private salaries, and the impact of these factors on the research mission of schools. "This is a call to action," she said, emphasizing the need for a paradigm shift that would have students learning in patient-centered care systems rather than student/faculty-centered clinics. "Everything we do in terms of clinical care should be focused around patient-centered models," she said.
Anderson stressed the need to run dental clinics as a business. Within teaching hospitals, she acknowledged, there are always economic winners and losers, with the former balancing the latter so that, overall, the university makes money that it spends on medical education. The Ohio State University hospital clinics, for example, provide $65 million a year to the medical school. She suggested that dental education has the opportunity to do the same, but it will require changing to patient-centered delivery systems.
Anderson noted that dental school clinics have other ways to remain solvent, including being fully committed to becoming the community safety net for dental care. "We have to be the safety net," said Anderson, "and we have to lobby to get funding for it." She added, "This will require outcomes data showing that investing in dental education leads to a net gain for the public."
Anderson also stressed the importance of sharing financial information about the dental school with the faculty. At Ohio State, she said, the budget of the Office of Academic Affairs is online, showing where the provost puts the financial resources of the office. Anyone looking at the reports can see that increased student productivity in patient-centered clinics has the potential for having a direct impact on faculty salaries.
As for partnering with federally qualified health centers, Anderson said that this idea is worth pursuing. Further, she asked, "What’s wrong with putting students with private practice clinicians?" She told of a part-time faculty member at her institution whose practice is losing a partner. He proposed paying the university for a resident to be assigned to his practice. "I’m willing to do it," said Anderson.
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Faculty Responsibilities
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Dr. Kathleen Roth, president of the American Dental Association, introduced the discussion about balancing and distributing the responsibilities of faculty members within the proposed new model of dental education. Responsibilities include patient-centered care, offsite education, research, lecturing, administrative work, and service work. Bailit and Formicola described how the Macy study model recognizes and rewards all faculty members, whether they are primarily researchers, clinician educators, or both. Formicola stated that many academic medical centers have two tracks—tenure and clinical—and, depending on the faculty credentials, the school’s need, and faculty interest, the faculty member’s responsibilities are aligned with one or the other. Anderson added that academicians throughout their careers do more or less research or teaching depending on circumstances. Faculty members make different contributions at different times in their careers and should be rewarded for the work they do.
Another issue that garnered attention was about creating a scholarly environment and a culture of inquiry where basic science, medicine, and dentistry are wedded as topics of conversation in dental practice. It was pointed out that the patient care setting is the perfect one to blend all three in discussions about the patient’s history, disease, and course of treatment.
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Reimbursement Issues
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There was also discussion about Medicaid programs and how dental school clinics are reimbursed. Bailit mentioned situations in which Medicaid recognizes the contributions of a dental educational institution and reimburses at a higher rate, so that the school can put more time, effort, and resources into treating the underserved. Discussion continued about equal care for full pay, Medicaid patients, and the tension related to faculty and marketplace salaries.
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Cost Savings: Seniors Working Outside the School
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Discussion moved on to the cost advantages of having senior dental students work outside the school, whether in community health centers or the private practice environment. Dr. Bruce Graham, dean, University of Illinois at Chicago College of Dentistry, who has a working group exploring the Macy options, urged convocation participants to keep each other informed about experiences with regard to private practice-based dental education. The successes of the University of Colorado in this regard were brought up. So was the variety of reactions, some negative, from faculty members who are opposed to sending students into private practices or community clinics for training where they might be exposed to clinical techniques not taught at the dental school or considered to be of inferior quality by the faculty.
Anderson followed with a vital point about the attempt she sees to steer all students through one mode of training as provided by the dental school on-site clinics. She said she believes that exposing students to on-site and off-site clinics and private practices is important because dental students are bright and can get the most out of any setting by asking the right kinds of questions even under less than optimal circumstances. Dental students should be expected to recognize, and discuss, the differences between good and bad practices, she said. Other participants mentioned training students in clinical skills at an earlier stage so that they can begin their training sooner in private practice and clinics; this would leave time in the senior year for research and critical thinking.
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GME Funding
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Dr. Cecile Feldman, dean, University of Medicine and Dentistry of New Jersey-New Jersey Dental School, agrees that students are more productive in community-based clinics. From their experience at New Jersey, she stated that students were two to three times more productive in the off-site clinics and more productive when they return to the school clinic. She wondered what the financial statement would look like with half the senior year spent off-site. Further, she indicated that advanced education in general dentistry (AEGD) residents were productive and important to integrate into the teaching model, but she asked whether they can pay their own salaries from patient care revenue rather than from federal Graduate Medical Education (GME) funds.
In the following discussion, it was pointed out that, in the Pennsylvania Experiment, the AEGD students’ salary was covered by patient care revenues, so in a well-organized and well-managed patient-centered clinic program, AEGD residents should be able to cover their salaries and participate in the educational program for the predoctoral students.
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Faculty Involvement
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Dr. James Hupp, dean, University of Mississippi School of Dentistry, raised an issue about faculty outsourcing to community clinics to supervise students. Many faculty have made their careers in dental schools because of the value they see in collaboration, cross-disciplinary opportunities, and scholarly and clinical seminars, he argued. Discussion followed about the fact that younger faculty are likely to be more receptive to going off campus than older faculty; that implementation would occur over time, giving people a chance to grow accustomed to change; and that salaries could increase by 30 to 40 percent, driving participation. In addition, as Formicola pointed out, the Macy study does not call for merely taking full-time faculty and moving them into community clinics. Rather, it encourages making faculty members out of professionals in the community clinics and in private practice. This has been done by the fifteen Dental Pipeline schools.
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Vast Opportunities
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Dr. Gregory Chadwick, associate vice chancellor for oral health at East Carolina University and interim dean of the School of Dentistry, offered insights into the vast opportunities a system of what he called "service-learning centers" would have for standardizing learning, collegial activity, and research. He pointed out the advantages that electronic learning, data gathering, teleconferencing, and networking would provide for faculty and students. Research data, for example, could be gathered by students and faculty from throughout the network of service centers. Faculty from throughout the system could participate in meetings via electronic media.
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Meeting Other Student Needs
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The discussion continued with comments about addressing other needs such as students’ knowledge base in the basic sciences and in medical primary care management. Formicola cited feedback from over 500 dental students in twenty-one schools indicating that these students feel the current environment in on-site clinics creates ethical dilemmas for students and inefficient care for patients.4
The session concluded with comments by Bailit and Formicola emphasizing that the ideas presented by the Macy study group are not prescriptive, but rather are observations based on research data. Each school is a local business, they noted, where the home environment will determine which recommendations would be appropriate or adaptable to its own situation.
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REFERENCES
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- Bailit HL. The fundamental financial problems of dental education and their impact on education, operations, scholarship, and patient care. J Dent Educ 2007; 72(2 Suppl):14–7.
- Formicola AJ. Dental school clinics as patient care delivery centers: a paradigm shift in dental education. J Dent Educ 2007; 72(2 Suppl):18–20.
- Bailit HL. Models for funding clinical dental education: what’s likely and what’s not. J Dent Educ 2007; 72(2 Suppl):21–4.
- Henzi D, Davis E, Jasinevicius R, Hendricson W. North American dental students’ perspectives about their clinical education. J Dent Educ 2006; 70(4):361–77.[Abstract/Free Full Text]
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Dental education in contrast...
Faculty responsibilities
