4
The Mission of Education

The most visible mission of dental education is to develop future practitioners. Broadly stated, its basic goals are to (1) educate students to serve their patients and communities well and (2) prepare students to continue to grow in skill and knowledge over their lifetime in practice. This report throughout refers to ''education'' rather than "training" to emphasize that dentistry as a profession demands both intellectual and technical skills that depend on clinically relevant education in the basic sciences and scientifically informed education in clinical care.

This chapter starts by putting current curriculum critiques in historical context. It then discusses several major curriculum concerns within the framework of principles established in Chapter 1. Then, because a sound curriculum means little without capable faculty and students, two major sections consider the people who constitute the heart of a dental school and whose careful recruitment and continued development are essential to the educational changes proposed in this chapter. Although the emphasis is on predoctoral education, this chapter also examines the critical relationship between predoctoral and advanced education in general dentistry. Continuing education, sometimes viewed as part of a university's service mission, is here considered to be one more stage of a lifelong learning process that professionals must pursue and dental schools must support. Research and patient care, which are



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--> 4 The Mission of Education The most visible mission of dental education is to develop future practitioners. Broadly stated, its basic goals are to (1) educate students to serve their patients and communities well and (2) prepare students to continue to grow in skill and knowledge over their lifetime in practice. This report throughout refers to ''education'' rather than "training" to emphasize that dentistry as a profession demands both intellectual and technical skills that depend on clinically relevant education in the basic sciences and scientifically informed education in clinical care. This chapter starts by putting current curriculum critiques in historical context. It then discusses several major curriculum concerns within the framework of principles established in Chapter 1. Then, because a sound curriculum means little without capable faculty and students, two major sections consider the people who constitute the heart of a dental school and whose careful recruitment and continued development are essential to the educational changes proposed in this chapter. Although the emphasis is on predoctoral education, this chapter also examines the critical relationship between predoctoral and advanced education in general dentistry. Continuing education, sometimes viewed as part of a university's service mission, is here considered to be one more stage of a lifelong learning process that professionals must pursue and dental schools must support. Research and patient care, which are

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--> examined in Chapters 5 and 6, are critical in their own right but are also crucial contributors to the kind of educational enterprise recommended in this chapter. The discussion below tends to focus on dental schools as discrete entities. The committee did not, however, intend to understate the role of organizations such as the American Association of Dental Schools (AADS) or limited-purpose consortia of several dental schools as promoters of change. These groups serve many valuable purposes, for example, by stimulating discussion, facilitating communication about innovative programs, devising model approaches to common problems, providing technical support, collecting and analyzing information, and promoting good relationships with organized dentistry and others. Collective as well as individual effort is essential if the changes recommended are to be achieved. Curriculum in Context A curriculum embodies the values and vision of an institution and a discipline. As expressed in the principles stated in Chapter 1, dental education should be scientifically based, clinically relevant, medically informed, and socially responsible. It should emphasize outcomes as well as services, efficiency as well as effectiveness, and community as well as individual needs. It should prepare students to critically assess both new and old technologies and practices throughout their careers. Traditionally, faculty have largely controlled school and department decisions about what is taught, by whom, and in what fashion. As discussed in a later section of this chapter, among the most important and difficult factors affecting the direction and pace of curriculum change are those involving the composition, power, and disciplinary organization of faculty. Seventy Years of Curriculum Critiques In the course of this study, the committee heard a lively debate about the strengths and weaknesses of current curricula and the values and vision that curriculum reform should reflect. As the background paper by Tedesco underscores, most critiques of the dental curriculum are long-standing. The core concepts behind changes that are still being advocated date back several decades. Moreover, if the word "medical" were changed to "dental," the basic points of several persistent critiques of undergraduate medi-

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--> cal education could easily apply to dentistry (Enarson and Burg, 1992). The links between the Flexner report (1910) on medical education and the Gies report (1926) on dental education have already been cited in Chapter 2. In the 1960s, the report Planning for Medical Progress Through Education (Coggeshall; 1965) fore-shadowed the 1993 recommendations of the Pew Health Professions Commission. For example, it envisioned medical education as a "continuum" that begins with preprofessional years (secondary and collegiate), is marked by the M.D. degree as a "midpoint," and extends with continuous education and reeducation "until the professional life of the practitioner is finished'' (pp. 39-40). The Coggeshall report also stressed (as does this report) the importance of health professions schools as integral parts of the university. More recently, the 1992 report Medical Education in Transition (sponsored by the Robert Wood Johnson Foundation) argued that "there is [an] . . . urgent need for students to appreciate the relevance—and, indeed, the excitement—of applying today's scientific advances to the practice of medicine" (Marston and Jones, 1992, p. vi). That theme likewise runs throughout this report. One lesson of past reports is that the dental curriculum is not alone as a target for criticism. A more sobering lesson is that it is much easier to analyze and recommend than to act.1 The practical, political, and procedural demands of major shifts in course offerings and content test the stamina of those attempting change (AAMC, 1992; Hendrickson et al., 1993). As one educator put it, "Most deans would rather take a daily physical beating than try to make significant changes in the traditional [curriculum]" (Garrison, 1993, p. 344). Recognizing the difficulties of change, various organizations have tried to assist planning processes, demonstration projects, and other activities in dental schools. The Pew National Dental Education Program offers a model of this kind of private support. It funded strategic planning processes in 21 schools and implementation 1   Apropos of this, Renee Fox has observed this about a series of reports on medical education. They have appeared "at periodic, closely spaced intervals [and] . . . contained virtually the same rediscovered principles, . . . [they have included[ the same concern over the degree to which these conceptions axe being honored more in the breach than in practice, the same explanatory diagnoses [about[ what accounts for these deficiencies, along with renewed dedication to remedying them through essentially the same exhortations and reforms" (Fox, 1990, cited in Howell, 1992, p. 717).

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--> activities in 6 (University of California, San Francisco; Columbia University; University of Florida; University of Maryland; Oregon Health Sciences University; and University of Southern California). These projects are summarized in the background paper by Tedesco, and an initial evaluation of the programs is reported in Feldman et al. (1991). This committee's findings and recommendations are intended to provide additional guidance and leverage for those with the desire and the will to seek further and more widespread reform of dental school curricula. They are also intended to reflect the interconnections of the education, research, and patient care missions of the dental school and to place curriculum objectives in the context of changing concerns about faculty, students, financing, regulatory practices, and work force planning. Background Data The major source of quantitative data on the dental school curriculum is a series of annual education surveys conducted and published by the American Dental Association (ADA). The background paper by Tedesco presents additional historical data from many sources. Information from the survey of deans by the Institute of Medicine (IOM) and the American Association of Dental Schools is also included here. Through its site visits, survey of deans, public hearing, and other activities, the committee sought to supplement quantitative and written information with a more qualitative sense of the curriculum as experienced by students, faculty, and to a limited degree, patients. In some respects, this qualitative sense is another label for realism, an understanding of the practical and political challenges of change. Variations in Program Length and Density The dominant model of dental education is a four-year predoctoral program. One school (the last of a group of 16 that tried a three-year schedule during the 1970s) offers a three-calendar-year predoctoral program, and another has offered a five-calendar-year program that it is planning to reduce to four years. The predoctoral program is generally preceded by a baccalaureate degree with appropriate preprofessional coursework in the sciences. For the majority of dental graduates, it is followed by advanced education in general dentistry or a specialty.

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--> Beyond that common base lies substantial variability in program length and density. The length of the predoctoral program ranges from 120 to 187 weeks, with a mean length of 158 weeks.2 The number of weeks of instruction for the fourth year of dental school averages 38, with a range from 28 to 49 weeks (a 75 percent difference). Summers have increasingly been filled with academic requirements. For the four-year programs, total clock hours3 range from 3,450 to 6,635—an almost twofold difference. Clock hours per week range from 20 to 41; the median number of clock hours per week is 30. Many schools offer optional programs that allow qualifying students to combine baccalaureate and predoctoral coursework in a structured six- or seven-year program. Some schools cooperate with other university programs to offer joint degrees, for example, a D.D.S. and a master's degree in public health, business, or public policy. Variations in Instructional Allocations The variability in length of the total dental curriculum extends to individual components. Table 4.1 summarizes the two- to sevenfold differences among schools in hours devoted to basic, clinical, and behavioral sciences. The background paper by Tedesco reveals similar variation among schools in the hours allocated for 19. basic science, 24 clinical science, and 5 behavioral science categories. The background paper also summarizes historical data on clock hours and their distributions over the past 30 years. These data suggest a gradual increase in curriculum requirements. This committee did not chart statistical changes in clock hours by individual school, but the survey of deans, the site visits, and other information once again suggest considerable variation across schools. In the deans' survey, a near majority of dental school deans (25 of 54) estimated that overall clock hours of instruction had remained about the same for the past 10 years. Only five suggested that 2   Medical school curricula are similarly variable in length, ranging from 119 to 192 weeks, and the mean is 153 weeks (Jonas et al., 1993). 3   Clock hours may include lecture, laboratory, or clinic hours or some mix of these. They do not convert into credit hours at a fixed rate. For example, according to the 1993-1995 catalog of the University of Illinois at Chicago (University of Illinois, 1993), the first year includes 200 clock hours of gross anatomy for 8 credit hours and 20 clock hours of dental radiology for 1 credit hour. In the third year, 10 clock hours of introduction to research receives 1 credit hour.

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--> TABLE 4.1 Variability in Curriculum Requirements—Basic Sciences, Clinical Sciences, and Behavioral Sciences   Total Clock Hours Percentage of Total Hours Curriculum Low Median High Low Mean High Basic Sciences Didactic 447 574 1,770       Laboratory 52 206 584       Total 563 787 2,103 12 17 34 Clinical Sciences Didactic 678 1,001 1,535       Laboratory 398 726 1,208       Patient careintramural 415 1,938 2,740       Patient care extramural 8 119 1,798       Total 2,567 3,844 5,400 64 80 87 Behavioral Sciences Didactic 57 115 373       Laboratory 2 12 120       Total 57 123 373 1 3 5   SOURCE: Excerpted from American Dental Association, 1994c. hours had increased rather than decreased. A majority of deans reported some or substantial increases in clock hours in clinical sciences, practice management, research methods, and behavioral science instruction. For the next 15 years, a majority expected further increases in these areas, in clinical training at nontraditional sites, and in working with allied personnel. Twelve deans reported decreases in basic science hours, compared to 10 reporting increases. Decreases in preclinical instruction were reported by 14 deans, but 5 reported increases. A majority of deans (30) predicted that preclinical hours of instruction would drop further. The committee could not determine whether decreases in basic science hours represented a desirable pruning of marginally relevant material or a deemphasis of the scientific foundation of dentistry at a time when that base is becoming more important. Accreditation Standards and Curriculum Guidelines Curriculum content is influenced by the standards of the Commission on Dental Accreditation and the curriculum guidelines developed independently by the AADS. Curriculum guidelines, which are not enforceable in the same way as accreditation standards, are intended to provide useful models for dental schools

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--> that neither stifle innovation nor mire schools in detailed regulatory requirements. As described in more depth in the background by Tedesco, the AADS is redrafting the guidelines to focus on competencies that comprise a mix of skills, practices, and attitudes (or understanding) needed by dental practitioners. The accreditation standards (and the accompanying discussion) emphasize preparation for lifelong learning (5.1.1), education in scientific reasoning and problem solving (5.1.2), and application of basic science principles to clinical care (5.2.1). Patient assessment and coordinated treatment planning are also stressed (5.3). The charge that accreditation standards stifle innovation focuses, in part, on the detailed specifications in clinical areas and on the standard that "early specialization must not be permitted until the student has achieved a standard of minimal clinical competency in all areas necessary to the practice of general dentistry" (5.1.3) (CDA, 1993a, p. 489). The committee heard the accreditation standards commended for promoting many of the directions discussed below. It also heard complaints that the standards discouraged innovation. As discussed in Chapter 8, the committee's sense is that both arguments have merit. Issues and Controversies As noted earlier, 70 years of surveys and reports have identified curriculum problems that persist to a considerable extent today. Most criticisms can be grouped into at least five broad concerns. First, basic science concepts and methods are weakly linked to students' clinical education and experience. Second, the curriculum is insufficiently attuned to current and emerging dental science and practice. Third, many problems remain in implementing comprehensive patient care as a model for clinical education. Fourth, linkages between dentistry and medicine are weak. Fifth, the overcrowded dental curriculum gives students too little time to consolidate concepts and develop critical thinking skills that prepare them for lifelong learning. Integrating the Basic and Clinical Sciences Curriculum Structure As described in Chapter 2 and in the background paper by Tedesco, the 1910 Flexner report and the 1926 report by William Gies called

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--> for curricula that embodied the scientific basis of medicine, including dentistry. Intervening years have broadened the case for basic science education to prepare students to become practitioners who can critically appraise new strategies for patient care and apply them when appropriate and who can understand the relevant biological bases of oral health and disease. Education in the basic sciences should also provide the vocabulary and basic concepts for researchers and clinicians to communicate with each other (Ten Cate, 1986). Figure 4.1 (derived from Formicola, 1991) depicts graphically the traditional Flexner-Gies organizational scheme.4 It also presents two alternative models that illustrate curriculum innovations adopted after World War II by medical schools at Cornell, Colorado, and what is now Case Western Reserve (Marston and Jones., 1992). These new models also contain other innovative concepts including comprehensive patient care. The Flexner-Gies model concentrated basic science education in the early part of the medical and dental school curriculum. Over time, as dental schools settled into a four-year schedule, the first two years of the curriculum also incorporated preclinical instruction (e.g., tooth preparation for restorations). The traditional curriculum, although a great advance over the nonscientific curriculum that preceded it, has been criticized severely for divorcing basic science from clinical practice to such an extent that many students view basic science as a largely irrelevant hurdle that has to be passed before their "real" training begins (Neidle, 1986a; Prockop, 1992). "Preclinical curricula are stuffed with too many courses, too many lectures, and too many faculty hobby horses that leave students at the end of two years exhausted [and] disgruntled" (Petersdorf, 1987, p. 19). More specific criticisms include the following (see Vevier, 1987; Marston and Jones, 1992; Prockop, 1992; Pew Health Professions Commission, 1993). First, expectations that students can master the core basic science disciplines in the equivalent of four semesters are unsustainable and counterproductive given the explosion of scientific knowledge. Second, the emphasis on mastering facts 4   This model is also called the horizontal model because it has often been graphed with years on the vertical axis so that the last two years of clinical science are stacked horizontally above the first two years of basic science. Figure 4.1A shows a vertical rather than horizontal division because school years are consistently placed on the horizontal axis for each model.

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--> Figure 4.1 Alternative configurations of basic and clinical science education.  Note: AEGD = advanced education in general dentistry.  Source: Derived from Formicola, 1991.

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--> still prevails over mastering principles and methods. Third, Ph.D.-trained basic scientists are not, in isolation, well prepared to focus their courses on the concepts and knowledge that are most clinically relevant. Fourth, the preparation and focus of National Board examinations, despite revisions, reinforce these problems. Fifth, some of the more esoteric areas of the basic sciences are not really relevant to clinicians and should be identified and dropped. Although these criticisms have been directed at both medical and dental education, dental students face additional burdens under a traditional curriculum. Besides the basic science courses, they must fit a considerable volume of preclinical laboratory work into their first two years. More generally, it was suggested to the committee that locating basic science faculty in the medical school can contribute to a lack of accountability to the dental school and thereby to curriculum immobility and low research productivity. For the majority of dental schools (29 in 1992), the basic science faculty are shared with the medical school, and instruction for dental and other health professions students is negotiated (ADA, 1993f). Although these dental schools may contribute 10 to 20 percent of their budgets to medical schools for basic science faculty positions, they do not have direct control over the faculty, and this may make it difficult for them to influence course content, for example, the inclusion of clinically relevant topics and examples. Some interviews suggested that schools may receive little in return beyond instructional hours (e.g., no participation in research related to oral health issues). If more shared faculty can be interested in oral health issues, then the larger and more diverse pool of basic scientists available on such a basis may be an asset. Such a pool is also created when academic health centers organize all basic science faculty in a separate unit. Alternatives to the traditional curriculum propose a more gradual shift in emphasis from basic science to clinical education. The objectives, which this committee endorses, are to reduce the disjuncture between instruction in the basic and clinical sciences and to encourage more "correlation" between the two throughout the predoctoral program. As depicted simply in Figure 4.1B, the goal is a gradual shift in educational emphasis rather than an abrupt chronological divide. In actuality, because coursework is generally blocked into discrete units (e.g., hours), the shift is better depicted as a stepwise rather than a continuous progression (Figure 4.1C). The revised figure still oversimplifies by omitting coursework in areas such as the behavioral sciences.

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--> Curriculum reorganization can do only so much, however. The link between science and practice must be demonstrated by faculty in both the classroom and the clinic. Thus, the modes as well as the content of education are important. Modes of Education Another shift from the traditional curriculum involves the introduction of instructional methods that attempt to reduce student alienation and disinterest by melding basic science principles and information with realistic analyses of clinical dental problems. Problem-based learning is perhaps the most notable example of such new approaches. Rather than view dental students as ''repositories of facts with psychomotor skills" (Tedesco et al., 1992), advocates of problem-based learning see students as acquiring an intellectual framework for practice and an understanding of the scientific method. In a sense, education is "what you have left after you've forgotten the facts" [Smith, 1985, cited by DePaola, 1986). At the risk of some oversimplification, traditional instruction and problem-based learning can be contrasted as follows. Traditional Instruction Problem-Based Learning Fact-oriented science Concept- and problem-oriented science Discipline-focused courses Interdisciplinary education Abstract knowledge Clinically related problems Larger classes Smaller classes Lectures Guided discussions Multiple-choice examinations Analytic examinations A number of dental schools have introduced problem-based learning in recent years, but little research documents its educational outcomes to date. Some medical schools, however, have up to 20 years experience with the approach. Two recent reviews of research on outcomes of problem-based versus traditional instructional methods indicate that the former was associated with greater student satisfaction; higher faculty evaluations; better clinical functioning; better performance on Part III of the medical board examinations (the problem-solving segment); and poorer performance on the Part I (fact-based) examination (Albanese and Mitchell, 1993; Vernon and Blake, 1993; see also Norman and Schmidt, 1992, and the background paper by Tedesco). One of these re-

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--> Figure 4.4 Dental schools, by size of enrollment. Source: American Dental Association, 1993a.

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--> highs of 17 percent in two schools and 41 percent at one school (ADA, 1993e). The last school alone accounted for nearly half of all enrolled foreign dental graduates, and two-thirds of such graduates were enrolled in just four private institutions. As noted in the background paper by Capilouto et al., the number of foreign dental graduates admitted with advanced standing to U.S. dental schools has grown sharply, nearly doubling from 1990 to 1992. Quality of Applicants and Graduates Improving the quality of applicants and admitted students was clearly a priority (either self-chosen or externally dictated) at several of the schools visited by the committee. These schools pointed to recent improvements in student credentials but acknowledged that they could not say whether these improvements reflected their recruiting efforts or other factors such as the decreasing attractiveness of M.B.A. programs. In the 1970s, increases in the number of dental school applicants and the ratio of applicants to enrollees were accompanied by increases in grade point averages and dental admission test scores (AADS, 1993b). The 1980s saw decreases in each area. Recent trends indicate improvements in applicant ratios and grade point averages. In addition, the attrition rate has dropped. In their survey responses, three-quarters of dental school deans agreed that dental school applicants were "better" today than five years ago. Although grade point averages were often mentioned during site visits and other meetings, the committee concluded that dental educators' views on shifts in student quality were not limited to this indicator but were also based on their first-hand experience with students over the course of many years. The earlier apparent drop-off in student qualifications may now be reverberating in initially higher failure rates on board and licensure examinations. For example, the percentage of U.S. graduates failing Part I of the National Board examinations increased fairly steadily from 9.6 in 1982 to 16.0 in 1992; for Part II, the failure rate went from 8.0 to 13.2 percent during the same period (ADA, 1993d).10 These trends may be another factor prompting schools 10   The Part II examination and scoring system was changed in 1992, but ADA tests of the new examination suggest the change did not affect failure rates (David Demarais, ADA staff, personal communication, August 23, 1994). In the three years preceding 1992, the failure rates were 13.4, 15.3, and 15.2.

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--> to pay more attention to how they recruit and educate their students. The relationships among the entering qualifications of dental students, their achievements in dental school, their success on licensure examinations, their subsequent performance in dental practice, and school evaluations during the accreditation process are discussed further in Chapter 8. In considering the quality of dental students and graduates, the committee developed some particular questions about graduates of foreign dental schools. ADA data indicate that these students are more likely to fail the National Board Dental Examinations (ADA, 1993c). For example, 48 and 39 percent failed the 1992 Part I and H examinations, compared to 16 and 13 percent of U.S. students, respectively.11 The committee found no data on the proportions of foreign dental graduates who never passed the examination and no follow-up data on those who eventually did pass. Information on clinical examination performance is not available. The committee recognizes that foreign dental graduates who do become licensed in the United States may provide needed services, and it opposes discrimination on the basis of nationality. Nonetheless, as discussed further in Chapter 8, the committee is troubled by shortcomings in the processes for assessing student performance and graduate competency, and it is concerned that these shortcomings may be even more serious for foreign dental graduates who enter with advanced standing. The committee urges dental educators, accrediting organizations, and related groups to assess current policies for the admission, education, graduation, and licensure of graduates of foreign dental schools and to eliminate admissions policies or other practices that may exploit these students or threaten the quality of patient care. Tuition and Debt Load In its visits to dental schools, the committee heard countervailing worries about tuition. On the one hand, tuition cannot continue to go up at the same rate as in the past; on the other hand, tuition is a major source of revenue for many schools. 11   This information is consistent with limited data on examination results for foreign medical graduates (Page, 1994). The medical examination data also indicate that American graduates of foreign medical schools have even higher failure rates.

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--> High student tuition is one of the most acute quality-of-life problems for many dental students and a major worry for dental educators. Figure 4.5 shows the change in tuition (in constant dollars) charged by public and private dental schools from 1970 to 1991. In 1970, tuition ranged from $67 dollars for in-state students at the least expensive school to $2,750 for all students at the most expensive. In 1991, the range was from $3,126 to $33,195. Other fees and living expenses add to total costs. For example, instrument purchase or rental can add thousands of dollars to students' costs. Not surprisingly, many dental students leave school with considerable debt, as illustrated in Figure 4.6. The high cost of dental education contributes to concerns that students from low- and middle-income families will lose access and that only those from wealthy families and those poor enough to qualify for substantial income-based financial aid will be able to afford dental school. In addition to considering the implications of the tuition and debt situations for both students and schools, the committee was Figure 4.5 Average resident tuition and fees in constant dollars by school type.  Source: American Association of Dental Schools, 1992.

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--> Figure 4.6 Student debt in constant dollars.  Source: American Association of Dental Schools, 1993b. concerned about the implications for practitioners and patients. During almost every site visit, the committee heard students admit that debt limited their options after graduation. Among the options discouraged are rural practice, short-term or career military service, practice in low-income areas, and academic or research careers. Several of these options involve settings with a shortage of practitioners. For example, the Department of Defense (1993, p. l) testified to the committee that ''the high level of indebtedness . . . [means that] many . . . who would consider serving in the armed services . . . cannot afford such a career. . .. All three services are well short of their recruiting needs." Some students who would prefer to go into practice say they opt for advanced education in part to put off debt repayment. For some but not all loan categories, interest charges are suspended during the training period. An additional incentive is the prospect of higher income with which to repay debt. Conversely, other students feel that they must start earning immediately after

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--> graduation, even if they would prefer a general practice residency or postgraduate specialty training. The fact that several categories of postgraduate training in dentistry neither pay a stipend nor waive tuition only adds to the difficulty. (Stipends are the norm in hospital-based programs, primarily for oral and maxillofacial surgery and general practice residencies; they axe common if not universal in pediatrics and advanced general dentistry.) In simple numerical terms, existing programs fall short as either debt relief or access improvement. Between FY 1991 and FY 1993, the National Health Service Corps (NHSC) increased the number of loan repayment positions from 11 to 55 (J. Rosetti, personal communication to M. Allukian, April 4, 1994). For 1994, 75 loan repayment positions were approved, but approximately 350 dentists were on a waiting list. Between FY 1991 and FY 1993, the number of scholarships decreased from 22 to 5, and none are projected in the future. In fact, the brochure describing the NHSC scholarship program does not even mention dentistry (AADS, 1994b). Efforts to control tuition and educational costs generally are discussed in Chapter 7 and in the background paper by Douglass and Fein. In addition to trying to control tuition costs, policymakers may ameliorate the debt problem to some degree by adopting or expanding programs of national service that link debt forgiveness to a period of practice in underserved areas.12 l2   The 1992 reauthorization of the Higher Education Act (HEA) changed the terms and conditions of many borrowing programs, particularly in the areas of deferment, interest capitalization, and repayment schedules. For example, the HEA created a direct loan demonstration program for institutions, in which participating schools will be designing programs that would allow income-sensitive repayment schedules. In the case of the most commonly used federal loan program, the Stafford, there is an increased focus on borrowers' needs in the allocation of interest subsidies. Instead of offering the same interest rate to all borrowers, an unsubsidized Stafford loan program has been created for those who do not show a need for interest subsidies. Most students are subject to interest capitalization during their undergraduate education unless the borrower makes interest payments while in school or qualifies for the need-based interest subsidy. Students pursuing postdoctoral educational opportunities are eligible for loan deferment with interest capitalization (except those awarded need-based interest subsidies). In addition, a loan consolidation program is available, that allows consolidation of certain loans with the option of graduated and income-sensitive repayment schedules and extended payback (up to 30 years, depending on the level of indebtedness).

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--> In FY 1993, the Health Resource Services Administration listed more than 1,000 dental shortage areas in need of over 2,000 dentists. The limitations of the NHSC program as a vehicle for improving access to care in underserved areas are discussed further in Chapter 9. Without greater public funding of this program, it will meet neither the primary goal of improved access nor the important secondary goal of helping students who are not wealthy retain access to dental education. Quality of Student Life During site visits, several specific initiatives to improve student instruction and quality of life were cited. Most of these initiatives were also expected to improve the quality of education. Specifically, upgraded admission standards would avoid the distress created for and by students who are not academically qualified (given available resources and reasonable expectations for special remediation programs) to tackle predoctoral coursework; revisions in instructional methods would discourage authoritarian and rote teaching, thereby reducing the stress associated with numerical requirements and factual recall; attempts to rebalance the curriculum would provide more stimulating education and more time to reflect on it; and efforts to create a sense of community among health professions students and to expand student exposure to the broader offerings of university life would improve the quality of life for dental students. The second and third of these directions—instructional and curriculum changes—have already been discussed. The fourth area reflects an acknowledgment that although the insularity of most professional schools—and dental schools in particular—has its comforts, isolation can be stifling. The committee was impressed by what it heard of efforts to create a sense of community among health professions students. These efforts are designed, in part, to increase the quality of services and support available to students by pooling library, housing, and other resources or activities and, in part, to enrich student life. Joint teaching of dental and other health professions students is intended to broaden the educational experience and promote the concept of health care as an enterprise involving teamwork and consultation. Enrichment of the dental school experience stretches beyond the health professions

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--> in the form of joint degrees and coursework involving a range of other schools and programs such as engineering, business, and health administration. A self-interested reason for dental educators to improve the quality of student life is that unhappy student memories may mean meager alumni contributions. Although such contributions are a relatively small part of school budgets they can relieve some of the pressure caused by cutbacks in public funding and greater competition for research funds. More generally, if practitioners retain negative feelings alter they graduate, this may contribute to the tensions between the education and the practice communities noted elsewhere in this report. Findings and Recommendations Because education is the most visible mission of dental schools, the committee commissioned a background paper on curriculum by Tedesco and focused many of its information collection activities on issues related to curriculum, faculty, and students. The committee examined extensive analyses of dental education. It also consulted numerous analyses of medical education to identify parallels and contrasts. The persistence of several common themes is striking and underscores the challenge of achieving change. The committee feels confident that most of those involved in dental education would agree that the following problems persist. Basic and clinical science teaching do not stress the basic sciences as a relevant foundation for clinical practice. Individual courses and the overall curriculum often reflect past rather than current practice and knowledge. Comprehensive care is more an ideal than a reality in clinical education, and instruction still focuses too heavily on procedures. Linkages between medicine and dentistry are insufficient to prepare students to comprehend and apply the growing medical core of dental practice. The curriculum is crowded with redundant or marginally useful material and gives students too little time to consolidate concepts or to develop critical thinking skills. Lack of flexible tenure and promotion policies and of adequate resources for faculty development limits efforts to match the faculty to educational needs. Despite progress, insensitivity to student needs is still a concern. All of these weaknesses undermine efforts to prepare students for lifelong learning. Many other reports have argued for movement away from these traditions and problems and have suggested specific alternatives including curriculum reform, education using active learning strategies

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--> such as problem-based learning, closer relationships between dentistry and medicine, new approaches to comprehensive care, and revised accreditation standards. The problem is not so much agreement on directions for change but difficulty in overcoming the obstacles to change. These include lack of specific information on course content, limited evaluation of educational impact, university policy restrictions, faculty conservatism, and regulatory and financial constraints. Suggestions and recommendations here or in other chapters address most of these obstacles, but each institution will have to tailor strategies to its specific circumstances. More generally, the kind of leadership and commitment emphasized in Chapter 7 is not something that can be transmitted through a report, although this report may—as stated early in this chapter—provide guidance and some leverage. The following recommendations emphasize curriculum reform, closer relationships with medicine, clinical experience in efficient practice settings, and student debt. They offer a mix of aspirations and instrumental actions to move toward desired goals. They need to be considered in conjunction with Chapter 6's recommendations about the patient care mission of dental schools, Chapter 8's consideration of licensure and accreditation policies, and Chapter 9's discussion of work force policies. To stimulate progress toward curriculum goals long endorsed in dental education, the committee recommends that dental schools set explicit targets, procedures, and timetables for modernizing courses, eliminating marginally useful and redundant course content, and reducing excessive course loads. The process should include steps to design an integrated basic and clinical science curriculum that provides clinically relevant education in the basic sciences and scientifically based education in clinical care; incorporate in all educational activities a focus on outcomes and an emphasis on the relevance of scientific knowledge and thinking to clinical choices; shift more curriculum hours from lectures to guided seminars and other active learning strategies that develop critical thinking and problem-solving skills; identify and decrease the hours spent in low priority preclinical technique, clinical laboratory work, and lectures; and complement clinic hours with scheduled time for discussion of specific diagnosis, planning, and treatment-completion issues that arise in clinic sessions.

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--> To prepare future practitioners for more medically based modes of oral health care and more medically complicated patients, dental educators should work with their colleagues in medical schools and academic health centers to move toward integrated basic science education for dental and medical students; require and provide for dental students at least one rotation, clerkship, or equivalent experience in relevant areas of medicine, and offer opportunities for additional elective experience in hospitals, nursing homes, ambulatory care clinics, and other settings; continue and expand experiments with combined M.D.D.D.S. programs and similar programs for interested students and residents; and increase the experience of dental faculty in clinical medicine so that they—and not just physicians—can impart medical knowledge to dental students and serve as role models for them. To prepare students and faculty for an environment that will demand increasing efficiency, accountability, and evidence of effectiveness, the committee recommends that dental students and faculty participate in efficiently managed clinics and faculty practices in which patient-centered, comprehensive care is the norm; patients' preferences and their social, economic, and emotional circumstances are sensitively considered; teamwork and cost-effective use of well-trained allied dental personnel are stressed; evaluations of practice patterns and of the outcomes of care guide actions to improve both the quality and the efficiency of such care; general dentists serve as role models in the appropriate treatment and referral of patients needing advanced therapies; and larger numbers of patients, including those with more diverse characteristics and clinical problems, are served. The committee recommends that postdoctoral education in a general dentistry or specialty program be available for every dental graduate, that the goal be to achieve this within five to ten years, and that the emphasis be on creating new positions in advanced general dentistry and discouraging ad-

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--> ditional specialty residencies unless warranted by shortages of services that cannot be provided effectively by other personnel. To permit faculty hiring and promotion practices that better reflect educational objectives and changing needs, the committee recommends that dental schools and their universities supplement tenure-track positions with other full-time nontenured clinical or research positions that provide greater flexibility in achieving teaching, research, and patient care objectives. To improve the availability of dental care in underserved areas and to limit the negative effects of high student debt, Congress and the states should act to increase the number of dentists serving in the National Health Service Corps and other federal or state programs that link financial assistance to work in underserved areas. Summary The education of future practitioners is the central mission of dental schools. The content and method of dental education have been the subject of many criticisms over the years related to the weak links between basic science and clinical education or experience, the overcrowded dental curriculum, and the isolation of faculty both individually and collectively from the world beyond departmental boundaries. Linkages between dentistry and medicine are weaker than the nature of oral health problems and the growth of medically oriented interventions warrant. Problems remain in implementing comprehensive patient-centered care. The persistence of these problems testifies to the difficulty of change. Although the next two chapters of this report catalog yet more problems in the areas of research and patient care, their recommendations focus on steps that would address not only those problems but also some identified in this chapter. For example, greater research involvement by clinical faculty would almost certainly reinforce the links between basic science and clinic education, and revitalization of the patient care mission would likewise help make clinically current and patient-centered education a reality.