7
Dental Schools and the University

Even in times of prosperity and comfort, universities reexamine their missions and the match between their missions and activities. Such reexaminations may lead to restructuring, consolidation, and elimination of programs. In times of relative financial strain, the incentives for such reexamination and redesign are markedly more intense, as dental educators can attest. Between 1984 and 1994, six private dental schools closed. During site visits and other discussions, the study committee learned that discontinuation of additional schools is a serious—although not necessarily publicly acknowledged—possibility.

This chapter examines the relationship of the dental school to the university, considers factors that put schools at risk, and assesses strategies for strengthening their position—including their financial position. A basic premise is that dental schools must remain part of the university rather than once again become independent institutions—essentially trade schools—without the relationships to other professional, scientific, and humanities programs provided by universities. To preserve and strengthen their position within the university, dental schools must ensure that their contributions are genuine and visible to their parent institutions.

As described in Chapter 2, the first university-based dental school was created at Harvard University in 1867, and the University of Michigan created the first postgraduate programs in 1894. A fundamental goal of William Gies's 1926 report on dental edu-



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--> 7 Dental Schools and the University Even in times of prosperity and comfort, universities reexamine their missions and the match between their missions and activities. Such reexaminations may lead to restructuring, consolidation, and elimination of programs. In times of relative financial strain, the incentives for such reexamination and redesign are markedly more intense, as dental educators can attest. Between 1984 and 1994, six private dental schools closed. During site visits and other discussions, the study committee learned that discontinuation of additional schools is a serious—although not necessarily publicly acknowledged—possibility. This chapter examines the relationship of the dental school to the university, considers factors that put schools at risk, and assesses strategies for strengthening their position—including their financial position. A basic premise is that dental schools must remain part of the university rather than once again become independent institutions—essentially trade schools—without the relationships to other professional, scientific, and humanities programs provided by universities. To preserve and strengthen their position within the university, dental schools must ensure that their contributions are genuine and visible to their parent institutions. As described in Chapter 2, the first university-based dental school was created at Harvard University in 1867, and the University of Michigan created the first postgraduate programs in 1894. A fundamental goal of William Gies's 1926 report on dental edu-

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--> cation was to improve the stature of these university-based programs and eliminate nonuniversity programs. Likewise, when the National Institute of Dental Research (NIDR) was established in 1948, it rested its research strategy on the proposition that a university base for dentistry was essential to long-term progress in oral health science. This stance reflected a broader, postwar consensus that scientific research was fundamental to the nation's health, well-being, and security and that the country's universities and colleges had to play a central role in advancing knowledge and developing scientific talent (Bush, 1945). The University In A Changing World America's universities have, since the end of World War II, experienced phenomenal growth and prosperity followed by some degree of retrenchment and instability born of slow economic growth, rising costs for research and development, and increased competition from other calls on society's resources (Williams et al., 1987; President's Council of Advisors on Science and Technology, 1992). Although the situation varies significantly from school to school and from state to state, the pressures on the university and the academic health center have generally intensified in the last decade. These pressures include federal policies that have added or shifted responsibilities to other units, including states and academic health centers. Resources often have not been shifted or expanded to reflect costly added responsibilities in areas such as occupational health and safety and indigent health care. Indeed, federal and state resources for many longer-standing programs either have not kept pace with inflation or have declined far below the levels that promoted growth in the 1960s and 1970s. At the same time, budgets in many states have been severely strained by a slow and uneven recovery from a prolonged recession, difficult social problems, and public opposition to taxes for almost any purpose. Educational costs, in common with costs for other service sectors of the economy, have been increasing at rates considerably higher than family incomes and inflation overall (Baumol, 1992). Most of this differential is attributed to rising labor costs that are difficult to offset by increased productivity, for example, through the replacement of people with machines. One result is concern that tuition may be reaching the limit of affordability, particularly at some private institutions. Physical facilities added during the expansion years of the 1960s and 1970s are wearing out, and keeping up-to-date technologically

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--> is expensive, particularly in academic health centers. Some attribute a large part of health care cost increases to technological innovation (Newhouse, 1992). Success during the 1960s and 1970s in attracting new resources multiplied new programs and units, thereby increasing administrative costs and complexities and adding to the number Of interested parties (e.g., faculty, students, interest groups) that resist program cutbacks (Detmer and Finney, 1993). University efforts to cut costs by downsizing or reorganizing have also been limited by the tenure system and by the elimination of mandatory retirement Honan, 1994a,b).1 In addition, demographic changes have created strains as the ''baby boom'' generation has aged out of its undergraduate years and been replaced by a new mix of students—more women, minorities, and older students—with different characteristics and expectations of the university. Moreover, universities have been criticized. for arrogance and lack of accountability, for neglecting their fundamental educational role, and for overemphasizing the theoretical at the expense of the practical (see, for example, Boyer, 1990; Searle, 1990; Huber, 1992; Bulger, 1993). States, in particular, expect public universities to return visible economic benefits to their economies. At the national level, the President's Council of Advisers on Science and Technology (1992) has urged universities to be more selective in supporting programs and to reduce support for those that are not "world class." It also urged the government to refrain from encouraging new university programs for which sustained support is unlikely and from increasing the net capacity of the system of research universities. One problem universities face in developing coherent responses to environmental threats is a generally decentralized organizational structure based in a long tradition of academic autonomy. Within this environment, academic health centers have a unique 1   Universities are, in fact, scaling back programs. In a widely publicized example of retrenchment related to state economic problems, the University of California at Los Angeles has attempted to eliminate, consolidate, and restructure several of its major professional programs. It proposed to focus resources and cut administrative expenses by eliminating schools of public health, library science, architecture, and urban planning and by consolidating some of their curriculum, students, and faculty in other programs. After an outcry from the public health community and its supporters, the initial proposal has been revised, for example, to continue the School of Public Health, albeit on a scaled-back basis (Mercer, 1994).

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--> and often controversial position. They have made major contributions to university influence and prestige and simultaneously created significant tensions (Shapiro, 1994). With their considerable budgets, staffs, and reputations, these centers sometimes provoke resentment as well as concerns that university ideals are compromised by the exigencies of professional education. Bulger (1993) also points to cultural tensions: "The health professional schools on the academic health center campus are involved with teaching and research, and in addition actually do something with their students, whereas most programs in the rest of the university do not lead to efforts in the field of action for which the faculty are held responsible" (p. 204). In addition to the general pressures on the university as described above, academic health centers face additional challenges deriving from the restructuring of the health care delivery and financing system. Chapter 6 describes these challenges and argues that dental schools may be either an asset or a liability in this environment. Schools at Risk As noted in Chapter 1, one inspiration for this study was the decision by six universities—all private—to close their schools of dentistry in the 1980s and 1990s (see Table 1.1). Several more schools—some private, some public—have been given mandates by their universities to improve or risk closure. What puts a dental school at high-risk?2 The committee's investigations pointed to several factors. Financial issues were repeatedly described as critical. Dental education was cited as an expensive enterprise that is or may become a drain on university resources. On average, current-year expenditures for the average dental school are about $1 million more than current revenues. Uncompetitive patient care programs may become an increasing liability in the future. The declining size and quality of the applicant pool during the 1980s played a 2   For discussions of specific schools, see Elliott, 1988; Fritz, 1988; Wotman, 1989; and Stephens, 1993. Also relevant are the strategic analyses of schools that received support from the Pew National Dental Education Program (see, in particular, the February 1990 issue of the Journal of Dental Education; and Barker and O'Neil, 1999). For governmental assessments of the possible closure of public or private state-related schools, see Kentucky Council on Higher Education (1992) and Wisconsin Governor's Commission (1993).

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--> role in some closures by threatening the tuition base and prestige on which private schools rely. Faculty and alumni resistance to change may feed impatience among university administrators. In some institutions, the comparative isolation of dental schools within the university has provided them with few allies or at least informed colleagues and has left them ill-prepared to counter proposals for "downsizing." Isolation also makes it difficult for the dental school to correct the misperceptions that caries are no longer a problem and that an oversupply of dentists makes continuation of most schools unnecessary. In addition to "cultural" isolation, some schools face geographic isolation from peer professional schools. Finally, the limited involvement of some schools in their surrounding communities leaves them without support from this potential constituency. The above recitation lists factors that are, to varying degrees, both within and beyond the control of any dental school. Earlier chapters have discussed steps—including faculty practice plans, collaborative research, community health programs, and minority recruitment strategies—that should reduce the isolation of the dental school and serve other goals as well. From a dean's perspective, however, even the elements for which the school is held most accountable (e.g., faculty productivity) may not be easily amenable to change by management. As discussed elsewhere in this report, constraints include policies related to tenure and retirement age, shortages Of qualified oral health researchers, and political disputes over expanded dental school services in the community. Because financing has been identified as such a crucial factor, the next section of this chapter considers the financial position and options of dental schools. It does not promise easy answers. Financing Dental Education In the committee's survey of dental school deans, financing stood out as a major issue. When asked to identify the most significant weaknesses of their schools, 47 out of 54 deans mentioned overall funding problems or specific funding problems related to overreliance on tuition. The senior university officials interviewed by the committee uniformly pointed to financing as their most immediate concern. The following discussion of dental school financing highlights selected data and issues, and the background paper by Douglass and Fein presents a more extensive analysis.

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--> Basic Data Overall, from 1985 to 1993, mean revenue per dental school increased from $14.0 million to $21.0 million for public schools and from $11.5 million to $18.9 million for private schools (ADA, 1994a). Both of these increases exceed the 34 percent increase in the Consumer Price Index for the same period. Table 7.1 presents trend data showing changes in the proportion of dental school revenues from different sources from 1973 to 1991. The cutbacks in federal share and the increases in the state share of funding show up for both public and private schools. The proportion of state funds increased for private schools (including private state-related schools) from 8.3 percent in 1973 to 19.4 percent in 1981, but the figure had dropped back to 9.2 percent by 1991.3 The proportion of state funds has also dropped for public schools in recent years, but these funds still comprise, on average, over half the revenues for these schools. Nearly half the revenues of private school derive from tuition. For all dental schools in 1992, the average total expenditure per student was nearly $53,000, of which about 30 percent was recovered through tuition, student fees, and clinical revenues (Table 7.2). Behind these overall figures lie major differences between public and private schools. The average total expenditure per student was about $60,400 for public schools and $39,1100 for private schools. The former recovered about 20 percent of these costs from student tuition and fees and clinic revenue compared to 64 percent for private schools. State appropriations account for most of this difference between public and private schools. Variations in total expenditures per student vary even more dramatically at the level of the individual school. Excluding expenditures for sponsored research, the 1992 expenditures per stu- 3   The figures for private schools include schools categorized as private state related. In general, these schools appear more similar to each other in expenditures, staffing, and tuition than they are to public schools. In rank order, the six private state-related schools received approximately 55, 30, 26, 20, 9, and 3 percent of their revenues from state appropriations in 1993 (ADA, 1994a). Of the 13 private schools not categorized as state related, six received from 0.16 to 2.16 percent of their revenues from state appropriations. Among public schools, revenues from state appropriations ranged from 27 to 75 percent of total revenues. From 1993 to 1994, one private state-related school closed, and another changed its classification to private.

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--> TABLE 7.1 Sources of Dental School Revenue as Percentage of Total Revenue Source 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 All Schools State 36.0 37.9 45.9 47.6 49.5 46.6 45.1 44.4 45.2 42.4 Federal 29.9 27.6 19.1 16.1 13.2 10.1 12.2 10.1 10.9 10.5 Tuition 17.3 16.6 17.3 19.3 19.9 23.5 23.1 22.3 21.0 22.0 Clinic 9.1 10.4 11.2 11.8 12.8 13.4 13.5 13.8 13.8 15.3 Other 7.7 7.5 6.5 5.3 4.6 6.4 6.1 9.3 9.0 9.9 Public Schools State 53.2 53.6 61.6 64.1 66.0 64.7 62.7 61.6 60.2 57.6 Federal 26.5 24.2 17.0 14.9 12.3 9.9 11.8 10.4 10.8 10.4 Tuition 8.2 7.9 8.0 8.6 8.7 10.5 10.3 10.0 10.0 10.4 Clinic 6.4 7.7 8.4 9.3 10.2 11.3 11.5 11.6 11.7 13.4 Other 5.6 6.6 5.0 3.1 2.8 3.6 3.8 6.4 7.2 8.2 Private Schools State 8.3 12.5 18.3 18.7 19.4 16.5 15.3 13.2 11.8 9.2 Federal 35.3 33.0 22.8 18.1 15.0 10.2 12.8 9.7 11.0 10.7 Tuition 32.0 30.7 33.7 37.8 40.4 45.1 44.8 44.7 45.5 47.3 Clinic 13.5 14.7 16.1 16.2 17.5 17.0 16.9 17.8 18.5 19.2 Other 10.9 9.1 9.1 9.2 7.7 11.2 10.2 14.6 13.2 13.5   SOURCE: Adapted from American Association of Dental Schools, 1993b. dent ranged from $26,300 in one medium-sized private school to $91,600 in one small public school. One explanation for the differences between public and private schools is that public schools are generally smaller, averaging just under 300 students per school, whereas private schools average just over 400 students. This means that fixed and semi-fixed costs are spread across a smaller student base. Private schools average 5.46 students per faculty member compared to 3.87 for public schools. Do variations in expenditures per student indicate that private schools are more efficient than public schools? Beyond the size variable, the committee lacked the information to make such a determination. True educational costs per student are not easy to determine, and the committee found no in-depth empirical analyses of the actual costs of dental education. Likewise, a 1993 report from the Josiah Macy, Jr., Foundation found no recent analyses of the cost of medical education (Ginzberg et al., 1993). In fact, the only systematic in-depth study identified in the Carnegie re-

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--> TABLE 7.2 Dental School Expenditures and Revenues per Student, 1977-1991 (in dollars) School 1977 1981 1986 1989 1990 1991 1992 All Schools Total expenditures per DDSE 17,463 23,927 36,568 47,198 49,628 51,447 52,804 Average resident tuition and fees 2,824 4,933 7,556 8,867 9,427 10,106 10,690 Clinic revenue per DDSE 1,768 2,213 3,522 4,165 4,645 5,016 5,515 Remaining cost per student 12,871 16,781 25,490 34,166 35,556 36,325 36,599 Percentage of total cost not recovered in tuition, fees, or clinic revenue 73.7% 70.1% 69.7% 72.4% 71.6% 70.6% 69.3% Public Schools Total expenditures per DDSE 20,412 27,349 41,776 54,419 57,037 59,226 60,366 Average resident tuition and fees 1,442 2,241 3,783 4,813 5,106 6,074 6,188 Clinic revenue per DDSE 1,553 1,870 3,166 3,901 4,336 4,800 5,341 Remaining cost per student 17,417 23,238 34,827 45,705 47,595 48,352 48,837 Percentage of total cost not recovered in tuition, fees, or clinic revenue 85.3% 85.0% 83.4% 84.0% 83.4% 81.6% 80.9% Private Schools Total expenditures per DDSE 13,617 18,937 28,972 34,876 36,663 37,833 39,157 Average resident tuition and fees 4,808 8,702 13,297 15,962 16,990 18,090 19,443 Clinic revenue per DDSE 2,046 2,715 4,041 4,629 5,185 5,395 5,819 Remaining cost per student 6,763 7,520 11,634 14,285 14,488 14,348 14,309 Percentage of total cost not recovered in tuition, fees, or clinic revenue 49.7% 39.7% 40.2% 41.0% 39.5% 37.9% 36.2% NOTE: DDSE - D.D.S. undergraduate equivalent. The American Dental Association equivalency formula counts advanced specialty student as equal to 1.7 of a predoctoral (D.D.S.) student and an allied dental professions student as equal to 0.5 of a predoctoral student. SOURCE: American Dental Association, Council on Dental Education, annual reports.

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--> port was a study conducted by the Institute of Medicine (IOM, 1973) in the early 1970s.4 One problem in determining true costs for education is allocating costs for jointly produced services such as teaching and patient care. Another problem arises when schools use residents in their advanced general dentistry or specialty programs to instruct predoctoral students. Moreover, in comparing costs across schools, one would—ideally—want a "quality-adjusted" measure of output that would indicate whether higher cost is associated with better student performance, for example, in licensing examinations and in practice. In addition, because schools may differ in the abilities of students recruited, one would want to know the "value added" by different schools. Table 7.3 compares sources of revenues for dental and medical schools. It shows that dental schools rely more on tuition and fees (22 versus 4 percent) and less on faculty practice income (15 versus 42 percent.5 The latter difference reflects the significant— but vulnerable—contribution of Medicare and Medicaid reimbursements for graduate medical education. Variations in the cost of dental education are replicated in costs for dental hygiene education. The average cost in dental hygiene tuition and fees is approximately $4,500 at community colleges, $5,800 at technical institutes, $7,000 for four-year colleges, and $10,000 for dental school and university-based programs (Solomon et al., 1992). At private universities, tuition may exceed $20,000. Dental hygiene programs are relatively costly for educational institutions compared with many other allied health professions programs. Allied health education is, in general, expensive for institutions because it is faculty intensive, often demands expen- 4   The 1973 IOM study worked from a statistical sample of 14 medical schools and relied in part on data derived from diaries "in which the faculty members logged their time by activity—education, research, and patient care." For joint activities such as teaching and patient care, the faculty estimated the time allocated to each aspect. The data were converted into estimates of instructional costs and costs for patient care and research associated with education. Extrapolating from the 1973 study, the authors of the 1993 report estimated that the 1990 inflation-adjusted costs for educating a medical student averaged $38,000 with a range of $21,000 to $56,000. However, the average cost derived by dividing instructional and department research costs was $68,000. The authors do not offer an explanation for the differences in the two approaches. 5   Comparisons between medical and dental schools should be treated as provisional because of possible differences in definitions and reporting conventions not known to the committee.

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--> TABLE 7.3 Sources of Income and Revenue for Dental Schools and Medical Schools, 1990-1991 (in $millions)   Dental   Medical   $ Amount % of Total $ Amount % of Total Operating Revenue State 426.1 42.4 2,714 12.9 Federal 10.9 1.1 104 0.5 Tuition 221.2 22.0 876 4.2 Clinic/services 153.2 15.3 8,848 42.1 Endowment earnings 12.6 1.3 403 1. Gifts 16.3 1.6 448 2.1 Indirect cost recovery 24.8 2.5 1,385 6.6 Parent university NA NA 189 0.9 Other 25.8 2.6 880 4.2 Total operating revenue 890.9 88.7 15,847 75.4 Nonoperating revenue Sponsored education, research and training Nongovernment 22.5 2.2 1,039 4.9 Federal 71.7 7.1 3,211 15.3 State/local 7.2 0.7 239 1.1 Financial aid revenue Nongovernment 4.2 0.4 196 0.9 Federal 2.8 0.3 142 0.7 State/local 5.2 0.5 332 1.6 Total nonoperating revenue 113.6 11.3 5,159 24.6 Total revenue 1,004.6 100.0 21,006 100.0 NOTE: NA - not available. Parent university support may be in the form of reduced physical plant expenditures, overhead, administrative, and other noncash benefits. SOURCE: American Dental Association, 1992d and Jolin et al., 1992. sive space and equipment, and involves administrative and supervisory costs to arrange and oversee off-site clinical activities. Thirteen university-based hygiene programs have closed since 1982 (one of which was transferred to another university), and two others are being phased out (ADHA, personal communication, May 23, 1994). Issues and Strategies Dental education, like medical education, is distinguished from professional fields such as law and business by the costs incurred in providing students with extensive clinical experience. In addi-

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--> tion, for dental schools, most of these costs are borne directly. Rather than relying on separate university-owned or affiliated hospitals as medical schools do, each dental school has its own large clinic dedicated to the clinical education of predoctoral students. The operation of these clinics subjects dental schools to financial requirements ranging from new government regulations to major technological innovations. The cost of these clinics is not shared with other users. Moreover, a substantial portion of expensive clinical faculty time is devoted to the unevenly paced and somewhat unpredictable task of reviewing the work of individual predoctoral students on individual patients. As medical schools move from hospital to outpatient settings for education, they too are encountering conflicts between the demands of patients land payers) for fast, timely care and an educational process that has its own pace and scheduling requirements. Contributing further to the financial pressures on dental schools are the expenses associated with many of the proposals for improvements in curriculum and instruction discussed in Chapter 4. For example, problem-based instruction involves higher faculty-to-student ratios and higher initial investments for developing instructional materials and training faculty. Similarly, student exposure to more varied patient care settings, generally off-campus, tends to add to costs and subtract from patient care revenues. Increased reliance on computers may cut some instructional costs by substituting less expensive machines for more expensive faculty, but computers are frequently a supplement, allowing more sophisticated instruction with substantial startup and ongoing maintenance costs. The financial problems facing dental schools are not merely the concern of the schools and their universities but also the concern of the profession and of society generally. In Chapter 1, the committee stated as one its guiding principles that "a qualified dental work force is a valuable national resource, and support for the education of this work force has come and must continue to come from both public and private sources." That principle, unfortunately, does not translate easily into practice. Financial survival requires that dental schools demonstrate their contributions to their parent institutions and to the public. Schools that fail to do so are vulnerable even if their financial situation is not critical. Schools that succeed will have better allies in times of crisis. Options No grand solution to the. financial problems of dental schools is on the horizon, and no single strategy or combination of strategies

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--> cific schools and their faculties and programs. Some of the key issues in such situations would be whether the strengths and weaknesses of the affected institutions are clearly identified, whether the expected benefits are being realistically assessed, and whether a merger strategy can resolve rather than exacerbate the problems. In other cases, regionalization might entail the closure of certain schools and a complex but not necessarily orchestrated reallocation of resources, some of which might flow to other dental schools and some of which might be retained by the university or the state that closed a school. The major financial objective of regionalization is to achieve educational economies of scale. Dental education, research, and patient care involve relatively high fixed costs for clinic facilities and equipment, laboratories, and specialized staff. A shift from a larger number of small schools to a smaller set of large schools should, over time, reduce costs per student and per patient at the remaining schools. Such a shift probably would simultaneously reduce the number of schools competing for research or other funds6 and increase the quality of the schools by concentrating academic talent that is currently spread thin, particularly in research. Consolidation of schools would, in many respects, be consistent with the "centers of excellence" strategy that is seen in other parts of the health care system and that is being promoted for research universities. The arguments against a regionalization strategy are both substantive and practical. In the short-term, consolidation may not save money. Consider, for example, an analysis of the implications of closing one of the two dental schools in Kentucky and shifting most or all of the closed school's enrollment to the remaining school (Kentucky Council on Higher Education, 1993; see also the council's 1992 report). This analysis (p. D-48) observed that the remaining school would experience substantial costs in "claiming or reclaiming, renovating, and equipping" the space required to nearly double its size and that additional costs would be incurred to relocate pro- 6   For example, if a closed school had been receiving research funds from NIDR, those funds might stay with the parent institution if an investigator could finish his or her work elsewhere in the institution (e.g., the medical school). Alternatively, funds might follow an investigator to another school. In any case, the closed school would no longer compete for NIDR funds so funds would implicitly be reallocated to remaining competitors (which include investigators elsewhere in the parent institution).

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--> grams displaced by such an expansion. In this particular case, some of the added costs would be offset by savings from the closed school (e.g., new construction costs forgone because expanding programs would be fitted into existing space). Moreover, although the committee knows of no evidence on the point, it suspects that the economy of scale argument may not apply for dental schools beyond a certain size.7 In schools beyond a certain size, faculty and students may also experience a loss of collegiality and freedom, and management structures may simultaneously become more oppressive and less efficient. A reduction in the number of dental schools would bring a loss of diversity. It would also make future expansion of dental enrollments more difficult should that be judged desirable in the future. Absent compensatory actions, regionalization of schools might reduce access to care for some patients and would cost jobs in "losing" communities. Further, the vagaries of state politics offer no guarantee that the schools to be closed would be those with weaker educational, research, and service programs. In addition, to the extent that consolidations were attempted across state borders, the distribution of expected costs and savings could create complications. Although a significant number of states do contract with out-of-state schools for positions for their students, the fungibility of state financial support for dental schools—a precondition for this strategy—is uncertain. Where consolidation is not feasible, cooperation among dental schools in the same state or region may still permit some cost savings. For example, schools might work together to develop extramural sites for predoctoral and postdoctoral training or to make specialized programs at one school available to students from another. Accreditation standards should be flexible enough to recognize this kind of experimentation and cooperation. University and State Policies and Priorities The financial strategies considered and adopted by an individual dental school (or imposed on it) will be contingent to some degree on the financial and other policies of the parent university or academic health center. Some institutions, particularly private universities, operate under an "every tub on its own bottom" 7   The literature on economies of scale in hospitals is suggestive but not necessarily generalizable (Zubkoff et al., 1978).

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--> policy. That is, educational programs must be financially self-supporting except under special circumstances. Some universities explicitly subtract a percentage of initial program budgets and then reallocate the funds from this across-the-board "tax" to subsidize or upgrade selected university programs. Depending on the state's financial condition and priorities, public schools may face periodic dictates that they cut their total expenditures by particular amounts and in specific ways (e.g., across-the-board rather than targeted cuts). To the extent that states lack special policies for budgeting capital expenses, up-front investments on behalf of educational, research, or patient care missions or in support of long-term financial objectives may be compromised. How the activities of a dental school correspond to state concerns can be crucial. For example, a 1993 analysis for the governor of Wisconsin (Wisconsin Governor's Commission, 1993) concluded that the most cost-effective way for the state to recruit an adequate supply of dentists overall was to contract with out-of-state schools to educate a defined number of Wisconsin residents rather than to continue to subsidize the existing private school in the state or to establish a new public school. The analysis, nonetheless, concluded that the contracting strategy was not desirable because the closure of the only dental school in the state would leave a major shortfall in services for the disadvantaged, especially in Milwaukee. Although Wisconsin considered contracting with out-of-state schools and several states without dental schools do that, other states essentially maintain a "free-rider" philosophy, assuming or hoping that other schools or states will bear the cost of training their dentists. Eighteen states have neither an in-state school nor a financial commitment for out-of-state training. This free-rider stance has been rationalized by the argument that an oversupply of dentists exists and that other states will continue to train and export dentists. With the closure of schools, the significant drop in enrollments, and the decline in the ratio of dentists to the general population, some dental schools eventually may be able to negotiate new agreements with noncontributing states. An alternative to this voluntary cost-sharing strategy might be a national policy for health professions education that recognized the limitations of state-based funding. Some proposals for health care reform have included a "trust fund" to support graduate medical education through a tax on health insurance premiums, although it is not clear that action will be taken on any of these proposals. Other issues aside, this trust fund concept would not address the public good and state equity issues in predoctoral education.

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--> Public and Private Schools The committee's view that dental education is a national resource deserving of both public and private support does not specifically address the situation of the nonprofit, private dental school. All six schools that closed in the last decade were private, and some other private schools are now at risk. How important is it that some private institutions be preserved? Is it important enough to warrant some public subsidy? In considering this question, the committee had to rely on perceptions and philosophies rather than empirical evidence about the value added by private schools to the nation's system of dental education. Certainly, private institutions such as Columbia, Northwestern, and the University of Pennsylvania stand out in the historical record of dental education. More recently, private schools initiated several of the curriculum innovations cited in Chapter 4. Yet, many public schools also have an impressive record of achievement and innovation. Ultimately, the committee's conclusion that a place for private institutions should be preserved rested on its conviction that a diversity of sponsorship and funding sources is desirable. In principle, such diversity can promote creativity, shelter challenges to conventional wisdom, help generate additional resources for testing new ideas, and diffuse power, including the power of the purse. Private schools may, for example, have greater flexibility and independence than state institutions. They also have provided opportunities for students whose states lacked a dental school and whose admission was limited by public schools in other states. For these reasons, the committee believes that public funding may, during difficult periods, be necessary and justifiable for private institutions. Public funds already flow to private institutions in many forms, including reimbursement for services to vulnerable populations, special projects, and competitive awards for research, training, and similar programs. Although not in the form of direct state appropriations for dental education, these funds may, to some degree, stem from a recognition of the value of private schools. Strengthening The Dental School Within The University Strengthening the position of dental schools within the university—on an individual and a collective basis—will require commitment from many sources. Some of this commitment must

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--> come from within the dental school, and some must come from the university or the academic health center. Support from state and federal governments is crucial in the form of both financial resources and prudent policies related to both health and higher education. In the private sector, it is important that organized dentistry, alumni, and community practitioners work to resolve tensions with dental educators that detract from their shared goals of quality professional education and improved oral health. Private philanthropy will not provide ongoing support, but it can provide crucial resources for specific projects. Risk reduction is not an overnight task, and some factors are less subject to a school's influence than others. This makes it all the more important that each school assess its own position and develop a strategic plan for reinforcing its position within the university. Although the specifics will vary from school to school, this strategic plan should generally include an analysis of the university's circumstances and expectations, an assessment of the dental school's objectives and of its strengths and weaknesses, and an identification of steps for building on strengths and correcting weaknesses. The three preceding chapters on the education, research, and patient care missions of the dental school have suggested specific strategies for modifying some of the factors that place schools at risk. They include improving the competitiveness of patient care programs in the community and building educational and research linkages with other parts of the university and academic health center. The middle section of this chapter considers financial strategies for improving the dental school's position. The following discussion focuses on leadership and service to the university. Leadership and The Challenge or Change Calls for better leadership may seem pro forma. They are, nonetheless, hard to forgo despite recognition that effective leadership, especially leadership to be exercised in difficult times, is not an easily purchased commodity or a readily created talent. One difference between the Flexner (1910) and Gies (1926) reports in the early years of this century and more recent examinations of medical and dental education lies in the strong emphasis of the latter on leadership and decisionmaking (see, for example, Association of American Medical Colleges, 1992; Pew Health Professions Commission, 1993; Ridky and Sheldon, 1993). Although Gies pleaded for university officials to upgrade dental schools and

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--> argued that lack of educational vision and understanding was a problem among deans (many of whom were expected at the time to continue in private practice), he did not focus on leadership as an issue in its own right. From its visits to dental schools and other activities, the committee came away with a strong sense that individual leadership from dental school deans was moving some schools down paths not otherwise possible. The characteristics of these individuals could not be studied in any depth, but no single style or personality type appeared to dominate. Important qualities appeared to include an active engagement with—but not simple capitulation to—the university and the external environment; a strong commitment to change tempered by intelligent appreciation of uncertainties and opposing arguments; and an evident dedication to the good of the school and those it serves. Leadership for change sometimes involves an expectation that a dean appointed to preside over dramatic restructuring will have a limited tenure rather than retiring from the position. Part of the explanation is ''burnout,'' the physical and emotional demands of reconstituting an institution. Another part of the explanation is that those who effect the changes outlined in preceding chapters may create animosities that must be assuaged by a subsequent leader. Dental educators have leadership roles that stretch well beyond the dental school. These roles include educating university, community, and state leaders about the continued seriousness of oral health problems, the disparities in oral health status, the projected downturn in the dentist-population ratio, and the challenges of oral health research. Dental school leaders can point to improvements in dental school applicants, as well as student and faculty contributions to the community in the form of patient care and other activities, and they can participate in the governance of the larger institution. Such strategies can help attract support from higher levels of the university or academic health center. Beyond the dental school, the highest levels of the university must also provide leadership that is sensitive to the particular circumstances of dental schools. The position of many U.S. dental schools is aptly summed up by the provost of a major state university in the "challenge of excellence" that he set in 1986 for the institution's dental school: "[The school] faces challenges and pressures today which are unlike any we have seen in recent history .... if there was ever a component of the University

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--> which had to learn how to respond to a world of change, it is [this school]" (Duderstadt, cited in Wotman, 1989, p. 700). This provost exercised leadership by backing his challenge with organizational and other resources. These included a "transition team" modeled on others used by the university in similar situations; interim positions for most of the school's administrators; recruitment of new leadership from outside; a more flexible budgeting structure with incentives for income generation by faculty and for early retirement for other faculty; pressure and direction for the reorganization of 18 departments into 6; and redefinition of appointment, promotion, and tenure policies. In several schools visited by the committee, the academic health center, the university, or a state body had initiated intensive reviews of the dental school. The study's survey of deans showed that more than a third had faced such a review (Table 7.4). The results varied but many included recommendations that the financial position, research productivity, and program quality be improved through changes in leadership, structure, and policies. In some cases, the continued survival of the dental school was made contingent on measurable movement in the recommended directions. The deans rated their university administration as relatively more supportive than their faculty of changes the deans wanted to undertake (Table 7.5). This is not surprising, given that the burdens of change—reorganization, financial cutbacks, and increased work loads—are likely to be experienced most acutely by faculty. TABLE 7.4 Number of Dental Schools Subjected to Intensive Review over the Last Five Years No. of Schools Category Excluding reviews related to institutional or programmatic accreditation, has your school been subject to intensive review in the last five years by any of the following? Check as many categories as apply. 40 a. Dental school at own initiative 9 b. Parent academic health center (AHC) administration 18 c. Parent university administration 2 d. AHC governing board 4 e. University governing board 11 f. State legislature   SOURCE: Institute of Medicine and American Association of Dental Schools, 1994.

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--> TABLE 7.5 Deans' Perceived Sources of Support for Changes in Educational Programs Weighted Rank Source How would you rate the following as sources of support for changes you believe need to be undertaken in your educational programs? 1 a. University administration 6 b. University governing board 8.5 c. Academic health centers (AHC) governing board 5 d. AHC administration 8.5 e. Accreditation standards 12 f. Requirements of licensure examinations 2 g. Clinical faculty 4 h. Basic science faculty 3 i. Alumni 11 j. Organized dentistry 7 k. Community groups 10 l. State legislature   SOURCE: Institute of Medicine and American Association of Dental Schools, 1994. During its site visits and other activities, the committee often heard faculty described as resistant to change. The survey, however, showed that deans nonetheless rated faculty and alumni as more supportive than, for example, state legislators or organized dentistry. The truth may be that faculty, by virtue of their critical numbers and responsibilities, are at once the greatest supporters of and obstacles to change. Service To The University Chapter 1 described the service mission of the dental school. Conceived broadly, it includes service to the university as well as service to patients and communities. Service in this sense is a form of leadership exercised in behalf of the university community as a whole by faculty, administrators, and even students of component parts of that community. Participation in university senates, ad hoc committees, and similar activities is sometimes exciting, sometimes tedious but, overall, essential for the governance, vitality, and sense of connection that binds the individual threads of today's complex universities together. If service to the university benefits the university, it is must also be emphasized that it benefits those who serve. When dental

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--> school administrators and faculty participate in university life, they build relationships and respect, develop facility in the peculiar world of academic politics, position themselves to influence decisions, and gain skill in communicating and even translating outside norms to their colleagues within the dental school. Participation in university affairs also offers the chance to learn more about academic management and to pick up ideas From others. Findings and Recommendations Dental schools must remain part of universities. The committee started with this premise, and its investigations into the future of dental education have reinforced it. To fulfill and improve their basic missions of education, research, patient care, and service, dental schools need the intellectual vitality, organizational support, and discipline of universities and academic health centers. Several factors make dental schools vulnerable as parts of universities. Risk factors include relatively high direct costs for education and patient care, low research and scholarly productivity, academic and professional isolation, uneven student quality, and resistance to change. Uncompetitive patient care programs are becoming a threat. Universities and academic health centers vary in their involvement in the community, so opportunities for dental schools to support university service in the community or even initiate their own programs will also vary. Two opportunities mentioned elsewhere in this report include patient care (Chapter 6) and educational outreach to minority youth (Chapter 9). Although education at all levels faces financial constraints ranging in severity from routine to critical, dental education faces particular problems given its relatively high costs, specialized needs, and in many cases, deliberate decisions to reduce enrollments. Although some might like to think that there is some kind of "silver-bullet" solution to financial problems, the committee suggests that this is unrealistic. The easy steps have generally been taken. Most schools will have to rely on some combination of difficult or tedious actions, including program consolidation, further reductions in operating costs, and persistent efforts to raise funds from alumni, government, industry, and other sources. The committee recognizes the challenges posed to dental schools of designing, implementing, and monitoring financial strategies in ways

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--> that minimize harm and provide support to the educational, research, and patient care missions of dental schools. Each school will need to tailor its own strategy to sustain and improve its position within the university and academic health center. A strategic plan that focuses on both financial and nonfinancial issues is an important starting point. To consolidate and strengthen the mutual benefits arising from the relationship between universities and dental schools, each dental school should work with its parent institution to prepare an explicit analysis of its position within the university and the academic health center; evaluate its assets and deficits in key areas including financing, teaching, university service and visibility, research and scholarly productivity, patient and community services, and internal management of change; and identify specific objectives, actions, procedures, and timetables to sustain its strengths and correct its weaknesses. To ensure that dental education and services are considered when academic institutions evaluate their role in a changing health care system, the committee recommends that dental schools coordinate their strategic planning processes with those of their academic health centers and universities. To provide a sound basis for financial management and policy decisions, each dental school should develop accurate cost and revenue data for its educational, research, and patient care programs. Because no single financing strategy exists, the committee recommends that dental schools individually and, when appropriate, collectively evaluate and implement a mix of actions to reduce costs and increase revenues. Potential strategies, each of which needs to be guided by solid financial information and projections as well as educational and other considerations, include the following: increasing the productivity, quality, efficiency, and profitability of faculty practice plans, student clinics, and other patient care activities; pursuing financial support at the federal, state, and local levels for patient-centered predoctoral and postdoctoral dental education, including adequate reimbursement of services for Medicaid and indigent populations and contractual or other arrangements for states without dental schools to

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--> support the education of some of their students in states with dental schools; rethinking basic models of dental education and experimenting with less costly alternatives; raising tuition for in- or out-of-state students if current tuition and fees are low compared to similar schools; developing high quality, competitive research and continuing education programs; and consolidating or merging courses, departments, programs, and even entire schools. Summary The integration of dental education into the university has been both a major accomplishment and an ongoing challenge. This chapter has identified risk factors that make dental schools vulnerable. Collectively and individually, dental schools should assess their strengths and weaknesses within universities or academic health centers and develop strategic plans to reduce risk factors. They need to see that their contributions to the missions of the university are both real and recognized. This will require leadership from within the dental school, reinforcement from the university, and support from the practitioner community.