told the committee that they could not afford to hire clerks to handle this responsibility and that patient payment before receipt of service was essential to financial survival. Similarly, educators often acknowledged that student clinics are generally understaffed with allied dental professionals but argued that they would further increase the clinic deficit by hiring more such personnel. Several of the schools visited by the committee were acutely aware of physical plant problems and had substantial renovations of their patient care space planned, under way, or recently completed.

Chapter 6, which looks at these circumstances from a patient's perspective, argues that dental schools must change their approach to patient care for ethical and practical reasons. In a health care environment marked by significant restructuring and serious challenges to the economic position of academic health centers, dental school clinics are poorly positioned to attract the growing numbers of insured patients (with or without health care reform) and to help the academic health center compete for health plan contracts.

In the broader context of the university and academic health center, efficiency considerations may argue for studies to determine whether consolidation of some aspects of the dental curriculum with other educational programs could generate administrative and personnel savings with no harm to (and, possibly, enhancement of) educational objectives. Although not a matter of efficiency per se, opening some dental school courses to students from other programs such as physical anthropology would make a modest contribution to reducing the isolation of dental schools, as discussed further in Chapter 7.

The combination of scientific and technological advances, academic traditions, and commitment to a four-year program has generated a curriculum widely regarded as overcrowded. With the conventional 40-hour work week used for comparison, the average dental student spends 30 hours in scheduled lectures, laboratory, or clinic work and has just 10 (theoretically) unscheduled daytime hours. Little of the formal curriculum is organized around the active learning strategies described earlier, and little time is left for critical reflection, consolidation of concepts and information, supplementary reading, or consultation with faculty.

The year as well as the week is packed with requirements. Only a handful of schools leave summers free for students to refresh themselves physically and mentally or to enlarge their