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Concerns About Finances, Faculty, and Clinics: A Dental School Dean’s Perspective on the Macy Study Report

Let me begin with some personal reflections. My choice of academic dentistry grew from an opportunity to participate as a scholar, from 1985 through 1987, in the Robert Wood Johnson Foundation Dental Health Services Program. Many thoughtful and generous dental academic leaders worked together in this program as members of the national advisory committee and as mentors and hosts for the scholars. Among these leaders were Allan Formicola and Howard Bailit. It was through this program that I first met dental faculty including Lisa Tedesco, Jeanne Sinkford, and many members of the group assembled at the Macy study convocation. The scholars program created a cohort of academicians with the skills and motivation to lead change in dental education. Just as we needed change agents then, we continue to need an army of change agents to lead the development and implementation of new models of dental education.

A take-home message, based on my personal experience in the scholars program and from the excellent work supported by the Josiah Macy, Jr. Foundation, is that private foundations working in collaboration with universities and academic leaders are critical partners in the effort to improve the education of health professionals and to create future academic leaders. I thank the Josiah Macy, Jr. Foundation for its investment in dental education and for providing us with the opportunity to gather at this important meeting.

As I prepared my remarks for the closing of the Macy study convocation, I reflected on the daily worries and concerns I face as dean at the University of Florida College of Dentistry. I made a checklist comparing my experience to the findings of the Macy study:

• Finances. I spend a significant amount of time focusing on college finances, budget transparency, accountability, fair and strategic allocation of resources, and fundraising.
  
• Faculty. Faculty recruitment, retention, salaries, quality of work-life, professional development opportunities, and finding/creating the academic leaders of the future are a major focus.
  
• Clinical operations. Also paramount are clinical operations, including business practices, information systems and infrastructure (e.g., purchasing and implementing a new clinic management system), patient and payer mix, patient satisfaction, and the timeliness and appropriateness of care.
  
• Accreditation. The University of Florida College of Dentistry is in the midst of an accreditation self-study. A site visit is planned for February 2008. Done correctly, this is a very time-consuming and potentially valuable process that encourages self-reflections and improvement.
  
• Ensuring that we are an integral component of the parent university. Our academic, research, and clinical programs must be well integrated into the fabric of the health center and university.
  
• Clinical education. The quality of education of our dental students, primarily clinical education, is always a priority.
  
• Constituent relations. I also spend a great deal of time on constituent relations. The constituents include faculty, staff, students, donors, alumni, practicing dentists, and agencies and organizations such as the Florida Dental Association and the American Dental Association.
  

How do these worries and concerns align with the Macy study? In answering, it is helpful to keep in mind the objectives of the Macy study convocation, which include the following: increase awareness of major stakeholders on the critical issues confronting the dental education system in the United States over the next decade; discuss strategies to address these critical issues; and create an action agenda for sustainable change.

	Worry #1: Dental School Finances

Top Worry #1: dental school... Worry #2: faculty issues Worry #3: clinical operations References

 
Dr. Dominick DePaola noted in his presentation at this convocation¹ that dental education is on the precipice of a crisis where costs are escalating, revenues are declining, student indebtedness is at an all-time high, and tuition is climbing to unprecedented and perhaps, unsustainable levels. The net result is that most schools are expanding fundraising efforts and increasing clinical income to cope with the changing economic picture. From my perspective, he is right on target! At the University of Florida, state support as a proportion of our operating budget is declining. We have increased tuition 10 to 15 percent each year during my five years as dean. Our average student indebtedness at the time of graduation has increased during this time, and students are increasingly concerned about the impact of indebtedness on their career choices and future financial health. I spend a lot of time fundraising, focusing on business practices, or in budget discussions with our college and university leadership. I would describe our college as financially healthy but vulnerable, and we need to be collectively concerned about the viability and sustainability of our educational model.

When I review the revenue sources for my college, I see that patient care revenue has become our largest revenue source, followed by sponsored grants and contracts, state appropriations, and tuition and fees (Figure 1). Gifts and endowments account for less than 2 percent of our operating budget. While I spend a considerable amount of time developing and maintaining donor and constituent relations, the expected payoff is in the future and most likely will not assist us with today’s fiscal challenges.

View larger version (21K): [in this window] [in a new window]   Figure 1. Sources of revenue at the University of Florida College of Dentistry Note: This pie chart shows that patient care at the University of Florida dental school is the largest source of revenue, followed by sponsored grants and contracts, state appropriations, and tuition and fees. Gifts and endowments account for less than 2 percent of the operating budget.

	Worry #2: Faculty Issues

Top Worry #1: dental school... Worry #2: faculty issues Worry #3: clinical operations References

A related worry regarding faculty is that we have a continuing discordance about how we define ourselves as dentists. Is a dentist someone who works in private practice thirty-two or more hours a week? Is a dentist someone who manages a community health center program? Is a dentist a scientist working on Sjögren’s syndrome research? Is a dentist someone who enhances your smile? Can we be all of these things? DePaola referred to "disconnects" in his discussion of drivers influencing dental education.¹ Our mental models of dentistry and academic dentistry are full of disconnects.

	Worry #3: Clinical Operations

Top Worry #1: dental school... Worry #2: faculty issues Worry #3: clinical operations References

 
If clinical revenue is to be an increasingly important engine financing dental education, then we need to pay more attention to how we are organized, how we conduct our business, and the roles and relationships among faculty, students, and patients. It will be increasingly important to pay attention to business practices, billing and collection for clinical services, technology infrastructure (including effective clinic management systems), patient and payer mix, and the timeliness and appropriateness of care and related patient satisfaction issues.

Likewise, if dental education is expected to serve as a significant safety net provider, I would argue that this can only be accomplished with some form of financial subsidy. For example, our system of clinics at the University of Florida currently generates about 100,000 patient visits per year, and about 85 percent of our patients live at or below 200 percent of the federal poverty level. This is a great public service, but if we are increasingly expected to become self-sustaining to ensure financial viability, we will most likely need to adjust our patient mix or limit the degree to which we provide uncompensated care or poorly compensated services, or find other funding sources to support this public service.

I agree with the conclusions from the Macy study calling for significant change in dental education. The background papers were helpful in reminding us of important events in our history including the Gies report of 1926, the Institute of Medicine report of 1995, the Pew Health Professions report, the surgeon general’s report, and the recent calls for curricular innovation and change led by the American Dental Education Association. Norman Vincent Peale said, "Change your thoughts and you change your world." We need to change in an informed, thoughtful, and courageous way to ensure the continued viability and respect of academic dentistry among our constituents and parent universities. Are we ready for change? It probably does not matter, because the world is changing around us. We need to understand our challenges and have the courage to take risks and try new strategies. Some will work and some will fail, but we will not make any headway unless we strategically evolve.

The Macy study convocation has provided the venue and opportunity to increase our collective awareness of the critical issues confronting the dental education system in the United States during the next decade. We discussed strategies to address these critical issues; now, it’s our collective responsibility to not only create an action agenda for sustainable change, but to carry these ideas and lessons back to our institutions, professional organizations, accrediting agency, and other groups and organizations that can facilitate these efforts. Individually and collaboratively, we need to take risks, experiment, and inspire others to join us in this process.

Perhaps the closing comments should reflect the opening keynote and discussion by University of Florida President Bernard Machen of the principles underlying educational reform.⁵ The most important to me as a dental professional is the first principle, "Dentistry is a learned, self-regulating profession that is comparable to, but organizationally separate from medicine." If we affirm this and the other six principles underlying educational reform proposed by the Macy study team,⁶ then we will have a strong and principled foundation for the necessary changes to our institutions and dental curricula.

	Footnotes

 
Dr. Dolan is Professor and Dean at the University of Florida College of Dentistry. She joined the faculty of the University of Florida in 1989 as the Director of Geriatric Dentistry. In 1991, the American Dental Association awarded Dr. Dolan the Geriatric Dental Care Award. In 1995, the American Board of Dental Public Health awarded her Diplomate status. Dr. Dolan previously served on the Executive Council of the American Association of Public Health Dentistry and received the President’s Award for service to the organization. Her research has focused on access to care issues, oral health promotion, and appropriate oral health outcomes for older populations. Dr. Dolan is a Phi Beta Kappa graduate of Rutgers University. She earned a D.D.S. degree from the University of Texas and an M.P.H. degree from the University of California, Los Angeles. She is a former Robert Wood Johnson Foundation Dental Health Services Research Scholar and a Veterans Administration Fellow in Geriatric Dentistry. Direct correspondence to her at College of Dentistry, University of Florida, 1600 SW Archer Road, Room D4-6, P.O. Box 100405, Gainesville, FL 32610-0405; 325-392-2946 phone; 325-392-3070 fax; tdolan{at}dental.ufl.edu.

	REFERENCES

Top Worry #1: dental school... Worry #2: faculty issues Worry #3: clinical operations References

 

1. DePaola DP. The revitalization of U.S. dental education. J Dent Educ 2008; 72(2 Suppl):28–42.[Abstract/Free Full Text]
2. Bailit HL. The fundamental financial problems of dental education and their impact on education, operations, scholarship, and patient care. J Dent Educ 2008; 72(2 Suppl):14–7.[Free Full Text]
3. Formicola AJ. Dental school clinics as patient care delivery centers: a paradigm shift in dental education. J Dent Educ 2008; 72(2 Suppl):18–20.[Free Full Text]
4. Bailit HL. Models for funding clinical dental education: what’s likely and what’s not. J Dent Educ 2008; 72(2 Suppl):21–4.[Free Full Text]
5. Machen JB. Will we allow dentistry to be left behind? Principles underlying dental education and practice. J Dent Educ 2008; 72(2 Suppl):10–3.[Free Full Text]
6. Formicola AJ, Bailit HL, Beazoglou TJ, Tedesco LA. New models of dental education: introduction to the Macy study report. J Dent Educ 2008; 72(2 Suppl):5–9.[Free Full Text]

This article has been cited by other articles:

				The Macy Study Team, A. J. Formicola, H. L. Bailit, T. J. Beazoglou, and L. A. Tedesco Introduction to the Macy Study Report J Dent Educ., February 1, 2008; 72(2_suppl): 5 - 9. [Full Text] [PDF]

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