Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares lessons from a 2014 ADEA Dean’s Conference presentation on ways that innovative dental schools are devising financially strong and educationally sound clinical education programs.

As promised last month, this Charting Progress will look at emerging practices that are helping schools maximize clinic revenue, improve their overall financial pictures and enhance clinical education in the process. Once again, we have a speaker at the 2014 ADEA Dean’s Conference last November to thank for the information I am about to share. John Reinhardt, D.D.S., who recently stepped down from his deanship at the University of Nebraska Medical Center College of Dentistry to rejoin the dental school faculty, told us what he learned from the research he conducted during his experience as the 2014 ADEA William J. Gies Foundation Education Fellow.

Using his connections with other dental school deans in the Big Ten athletic conference, John collected and compiled the kind of data that dental schools use to measure the financial health of their clinical programs. Dental schools generally do not share this type of data with other dental schools. However, these Big Ten schools have a history of sharing data with one another while maintaining confidentiality, which, John says, gives each institution strong evidence on which to chart its own individual path to improvement. Why might other dental schools want to share data? In John’s view, “Unless schools know how their clinical programs compare to others financially, those schools don’t know whether or where to seek improvements.”

John was surprised by the remarkable differences among schools his survey revealed, and so were those of us who heard his presentation. His survey looked at both dental residents and D3 and D4 students and asked about the number of clinic hours assigned, the average annual and hourly revenue collected per student and the fees for 20 key procedures. Here is a sample of what he learned about the nine schools.

  • Annual clinic hours for D3 and D4 students (combined) ranged from 1,500 hours to 2,700 hours, a difference of 80%.
  • Average hourly collections for D3 students ranged from $9 to $23, even though overall the fees charged by all schools were similar.
  • The highest fees charged for seven procedures commonly performed by dental students were more than double the fees at the schools that charged the least; for example, a complete removable maxillary denture ranged from $393 to $999.
  • Annual revenues per dental resident ranged from $29,000 to $194,000 for advanced education programs in pediatric dentistry and from $53,000 to $290,000 for advanced education programs in oral and maxillofacial surgery.

While there may be good explanations for the magnitude of these differences, they seem extreme given how much the Big Ten dental schools—all large, research-focused public universities—have in common. As John put it, “There’s something happening here that we need to explore.”

Fortunately for us, John plans to continue his research. This year he will invite all of our dental schools to participate in a survey to collect revenue-related data on a broader scale. Given adequate participation, the results should provide compelling evidence about which practices are effective and should help dental schools make informed decisions about clinical education and clinic management.

In the meantime, John has already gathered information on five innovative dental schools that others can look to as they contemplate how best to shape clinical education in the future. You can learn more from looking at John’s slides, but here, in a nutshell, are some of the lessons John learned about maximizing dental clinic revenue.

Missouri School of Dentistry & Oral Health (MOSDOH)

MOSDOH has eliminated its reliance on an in-school dental clinic by establishing a novel public–private partnership with Grace Hill Health Centers, a federally qualified health center (FQHC). MOSDOH, which just opened its doors to students in 2013, assumed responsibility for constructing a new dental education and oral health clinic in an area of high dental need in St. Louis and will retain ownership of the building. Grace Hill will be responsible for maintenance, supplies and clinical operations, with the two partners sharing revenue and risk.

Students will complete their initial didactic education in Kirksville, MO before relocating in their junior years to pursue clinical education at the Grace Hill facility. Senior students will spend about six months in externships at other community health clinics. The MOSDOH model has many advantages, including shared financing, access to enhanced Medicaid reimbursements and additional financial support under the Public Health Service Act. The facility also gives MOSDOH access to clinical faculty and helps the school fulfill the university’s mission to serve the community.

East Carolina University School of Dental Medicine (ECU SDM)

ECU SDM has retained its use of a campus clinic, but like MOSDOH, ECU SDM has transferred a large portion of clinical education to the community. The school has built eight 16-chair Community Service Learning Centers in underserved areas across the state, where each senior dental student spends three rotations of two months duration. Each center has a local partner, such as an FQHC, public health department, hospital or community college. To reduce costs and simplify management, all eight buildings have the same floor plan and use axiUm software. In addition, because ECU is a public school, it received state support for the construction, equipping and maintenance of the new clinical facilities.

The model also offers several educational advantages. Students gain experience managing business operations at a small multi-dentist clinic, and ease of data collection through axiUm creates opportunities for community-based research. The ability to collect and compare data will also allow ECU SDM to examine financial performance, productivity and health outcomes across the eight sites to further refine the school’s clinical education model.

University of Maryland School of Dentistry

The University of Maryland modified its approach to clinical education without building independent facilities. In 1985, the dental school spun off its clinic operations as a tax-exempt professional corporation, or a 501(c)(3). Although named the University of Maryland Faculty Dental Service Plan, the nonprofit encompasses all of the school’s clinics whether staffed by students, faculty and/or residents. Separating clinic operations from the university allows for greater business flexibility, making it easier for managers to hire, adjust work assignments, revise job descriptions, modify work hours and reward outstanding employees. The corporate model also encourages fiscal responsibility and streamlines purchasing by bypassing state approval for some purchases and bidding processes. Departments are allowed to retain half of the net revenues they generate, creating an incentive for clinics to increase income.

Virginia Commonwealth University School of Dentistry (VCU SOD)

VCU SOD also uses a 501(c)(3), VCU Dental Care, to manage its clinical operations and market its services to the public. VCU Dental Care was first formed in 1995 to oversee its faculty practice but has since evolved, incorporating residents in 2001 and dental and hygiene students in 2009. Like the University of Maryland, VCU Dental Care has more flexibility in handling business challenges. For example, the ability to hire outside state salary requirements and offer employee incentives makes VCU Dental Care a more competitive employer. The corporate system’s financial data reporting system also simplified VCU Dental Care’s ability to gather information needed to apply for federal Electronic Health Record incentive payments, which the clinics received. The corporation’s separate 501(c)(3) status has also allowed VCU Dental Care to earn money for its clinics by investing its reserve funds. Perhaps most impressive, VCU SOD has established a system of clinical performance incentives. Through its Variable Clinic Earnings incentive plan, VCU Dental Care contributed $2 million to faculty salaries in 2014.

Midwestern University College of Dental Medicine-Arizona

Midwestern University’s Arizona campus has taken, to my knowledge, a unique approach to clinical education that appears to be enhancing learning, patient care and the clinic’s bottom line. The school pairs its D3 and D4 students to work together side by side for a year with one serving as dental care provider and the other as a chairside assistant. The students switch roles as the complexity of their work dictates. When the D4 student graduates, his or her D3 partner is paired with a new student, and the team continues to serve the same cohort of patients in the year ahead.

This arrangement has multiple advantages over more traditional clinics in which students often operate without dental assistants. Patients benefit from continuity of care and receive more efficient service. Patients feel more secure since treatment is overseen by three sets of eyes (those of the student provider, the student assistant and the faculty supervisor). Students benefit from constant peer review, collaborative learning and the steady presence of a dental assistant. And finally, the clinic can operate more efficiently because it requires fewer chairs, fewer faculty and (since more treatment can be provided per visit) fewer disposable supplies to educate its students.

In comparison to the Big Ten schools, Midwestern-Arizona does well financially. Its fees fall in the average range for the Big Ten, yet they collect $62,000 per D3-D4 student pair annually on average, far more than the comparable Big Ten average of roughly $40,000. This amounts to $10 more collected per hour at Midwestern—no small accomplishment.

Each of these models is tailored to the specific needs, circumstances and goals of five very different dental schools.

“It always comes back to this: Is clinical education a byproduct of patient care, or is patient care a byproduct of clinical education?” John noted during his presentation. “It has to be a little bit of both, but how you look at that issue is what really determines clinical models, how dental care is delivered, and how dentistry is taught.”

It’s exciting to realize there are so many creative strategies available to dental schools looking to enhance clinical revenue and make changes to their curricula in ways that will improve the long-term financial prospects and educational strength of their programs. The willingness of the Big Ten schools and these five innovators to share information about their programs gives other dental schools an excellent basis for evaluating the many approaches to improving clinical revenue. Although each school will pursue its own unique course, the dental education community benefits from the availability of information on how other schools have tackled common challenges, and we appreciate John’s efforts to collect and share it.

John’s 2015 ADEA survey will provide us with a much larger evidence base that we can use to pinpoint problems and identify best practices. This may be critical if we are to overcome the economic challenges discussed in last month’s Charting Progress.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares the latest news on dental school application trends and other indicators confirming that the profession remains an attractive one.

It seems as though a day doesn’t pass without our hearing another story—often alarmist—about the skyrocketing cost of higher education. Even when the news is more measured, critics and supporters alike are increasingly asking hard questions about what students and taxpayers are getting in return for their tuition dollars.

While dental education has some unique strengths that should sustain it in the midst of this turmoil, our community is still part of the larger world of higher education and shares many of the same vulnerabilities. That’s why we asked Jane Wellman to speak at the 2014 ADEA Deans’ Conference last November about what is driving educational costs and shaping public perceptions of the value provided by our institutions. Jane is the Executive Director of the National Association of System Heads and Founding Director of the Delta Dental Project on Postsecondary Costs, Productivity and Accountability. A leader with experience in both government and nonprofit spheres, Jane has long immersed herself in public policy discussions surrounding postsecondary education. As expected, she was able to give us a nuanced and multi-dimensional explanation of how higher education is financed and some of the challenges we face. I am sharing that with you now.

While there appears to be consensus that the business model for higher education is broken, few critics truly understand that business model or appreciate the need to balance the four factors that make up what Jane called the “quadratic equation” for business success: value, resources, cost and processes. As a result, there is a lot of confusion and misinformation about what factors drive educational cost.

Jane argued that the public’s perception of the value of higher education is seriously “out of whack.” Until the 1980s, we associated the quality of higher education with the prestige of the institution, the money it attracted and the selectivity of its admissions. Jane called this an “input notion of quality” that conflates the business model elements of value (as perceived by consumers and investors) and resources (such as money, prestige, demand and personnel). In the 1980s and ‘90s, public opinion shifted to a notion of quality that focused on learning and outcomes. In this more practical, consumer-oriented view, value and resources were separated and a new mission emerged for colleges: to impart measurable skills.

This shift in how we measure value has coincided with a significant expansion in the portion of the U.S. population attending college and a parallel shift in how the public views the mission of this particular educational institution. Only 39% of Americans currently believe the purpose of college is to help people grow personally and intellectually. A majority of Americans now hold a more utilitarian view—college should be about getting a career and increasing earnings. While a college degree will still increase a person’s earning power in the long run, that value hasn’t increased at the same rate as tuition, and personal income is in decline. As a result, the benefit of getting a college degree relative to its cost is diminishing, and price has become a flashpoint for criticism. Many in the public are convinced that our schools are spending money on the wrong things—or at least on things that don’t tangibly contribute to the public’s new expectations regarding higher education output.

Jane took issue with this analysis, arguing that there are a variety of factors responsible for the rise in tuition prices that go well beyond the perceived spending problem that dominates public opinion. First, she directly attributed rising tuition rates to falling state appropriations to public universities even though, on their surface, some of the basic facts appear to contradict this assertion.

  • Nationwide, state appropriations for higher education more than tripled between 1987 and 2011.
  • Yet, when adjusted for inflation and enrollment, this tripling represented an increase of only 21%.
  • The result: When looking only at state general fund appropriations, adjusted for enrollments and spending, state funding for higher education declined between 1987 and 2011 by 20%—far higher than declines in funding for any other state function.

It’s no wonder there’s confusion. As Jane pointed out, all these statements are true.

I discussed state disinvestment in higher education in the February 2012 issue of Charting Progress, pointing out the inverse relationship that exists between state and local funding and student and family spending on tuition. In 2009, state and local governments were contributing only 38% of the cost of higher education, down from a high of 60% in 1975, and families were picking up more than half of the cost.

This phenomenon also affects our community. With fewer state dollars available, more of the burden of paying for dental education has shifted to the individual, leading to rises in both tuition and student debt.

Jane also provided data on the substantial increase in demand for higher education. While K-12 education grew by 21% between 1985 and 2010, postsecondary public education grew by 60%, private education grew by 102% and graduate education grew by 85%. Not only are more students seeking out higher education, Jane explained, they are doing so in more expensive fields. Thirty years ago, the majority of students sought degrees in the lower-cost humanities or social sciences. Now students flock to degrees such as business and engineering, which cost more to deliver.

Meanwhile, as prices have gone up, the growing practice of tuition discounting has driven college revenue down. Current CFOs find this practice, in particular, unsustainable. While universities have a variety of other revenue sources such as private gifts, endowment income, or revenue from auxiliary enterprises, most of the funds from these sources are not fungible. In other words, money from the building fund cannot be used to reduce tuition, meaning higher education institutions can’t always control how they spend their own money.

In the face of these challenges, Jane explained, higher education must also manage the use of cross subsidies instead of profit to cover the cost of varied programs. Because we lack transparency in pricing in education overall, the disconnect between cost and price becomes lost on the public. The typical consumer doesn’t see the way revenues from low-cost programs subsidize higher cost programs, or the way undergraduate programs subsidize graduate programs. This is especially true now that state subsidies have all but disappeared.

When looking for a culprit to explain increased price and cost, the public often looks to faculty salaries. In reality, spending on faculty amounts to less than half of spending in higher education. In fact, with the shift from tenured and tenure-line faculty to contract or adjunct positions, such significant cuts have been made that we should have concerns about how they affect quality. Faculty, meanwhile, blame increased costs on bloated administrations. While Jane acknowledged that some institutions have overhead costs that can’t be explained, she pointed to the cost of benefits—a cost outside institutional control—as the “smoking gun,” if indeed one exists.

Finally, Jane believes that the fourth element in her equation—processes for conducting business in higher education—is failing us. Jane asserted that traditions of shared governance, boards, accreditation, licensure and a budget-making process that cycles from year-to-year are not suited to resolving the complex challenges facing higher education. Among the evidence she cited: the fact that even the Association of Governing Boards acknowledges the need to address governance problems.

Despite this bleak outlook, Jane ended on a positive note. She believes we can find solutions to these problems if we remember the four components of our business model: value, resources, cost and process. Approaching it this way, she says, is “like solving a quadratic equation.” She doesn’t advocate for simply persuading the public that things are okay when clearly they are not. Rather, she urged us to address the accuracy of public perceptions while developing better processes, gathering more data, improving governance, examining cost structures and, of course, never giving up on revenue.

As promised at the outset of her talk, Jane’s presentation did a great deal to arm us with the concepts, language and data we will need to lead a more constructive conversation about our community’s financial future. You can find additional detail about her various points here.

We are fortunate in dental education that demand for our programs and our graduates’ earnings remain strong. Nevertheless, these strengths must be measured against a continuing rise in dental student debt and our relentless battle to ensure that economically disadvantaged students are not discouraged from entering our professions. Last year, ADEA conducted a survey of dental school deans’ perceptions of cost and borrowing, the results of which will appear later this year in the Journal of Dental Education. It revealed that our institutional members are taking an impressive range of measures to keep costs down and lower student borrowing.

One underappreciated cost driver in our community is the need to build and maintain clinical facilities in which to train our students. The pace of technological change in recent decades has only added to the costs associated with this enterprise. Next month, I will write about emerging practices that are helping schools maximize clinic revenues to improve this portion of the economic picture.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares the latest news on dental school application trends and other indicators confirming that the profession remains an attractive one.

In 2010, ADEA surveyed advanced education program directors and asked them to list the top qualities that are important to them in selecting candidates for their programs. Here are the attributes that ranked in the top five:

  • Team player
  • Assumes responsibility
  • Integrity
  • Interpersonal/communication skills
  • Reliability

When the responses of each dental specialty were looked at individually, critical thinking and clinical skills, or both, typically made their way into the top five as well. All but one specialty (more on that later) ranked academic talent dead last.

This finding may sound counterintuitive, but it shouldn’t be surprising. Academic talent is essentially a given among applicants to advanced dental education programs. Only high achievers make it into dental school to begin with, and no one graduates by being an academic slouch. But two developments—the decision in 2008 by the Joint Commission on National Dental Examinations (JCNDE) to move to pass/fail licensure exams in 2012 and the increased number of program applicants coming from dental schools that employ pass/fail grading—have raised difficult questions for advanced education programs accustomed to using National Board scores, grade point averages and class rank to help them screen and select candidates.

In anticipation of these challenges, ADEA created the ADEA Future of Advanced Dental Education Admissions (ADEA/FADEA) Project in 2009 to identify the best ways to review, compare and select candidates for advanced dental education programs. The project’s first activity was to conduct the 2010 survey and the results revealed a clear disconnect between the qualities program directors said they most valued, and the tools they were using to identify them. When the survey asked the directors to name the top factors they found most useful in evaluating candidates, letters of evaluation topped the list; but the three factors that followed—class rank, NBDE Part I scores and dental school GPA—indicated the difficulties that lay ahead. Come 2012, these numerical scores would no longer be available for some or all candidates, and perhaps more importantly, many in our community openly questioned their value in predicting professional success.

I wrote about the reasoning behind pass/fail grading in last month’s Charting Progress. In a nutshell, more and more students are choosing to go to dental schools that do not provide a GPA or class rank because they find the pass/fail grading environment more conducive to learning. And when it comes to scores on National Board exams, there is no evidence to support the notion that differences within the range of passing scores reflect meaningful differences in knowledge and ability among test takers, despite the common use of the exams to make these distinctions in the past. Furthermore, the inability of National Board scores to predict success in advanced education programs is borne out by program directors who tell us that struggling students rarely lack academic skills. Rather, their problems stem from a lack of interpersonal or communication skills, or an inability to function well in teams.

These qualities are the focus of the ETS® Personal Potential Index (ETS PPI), a web-based system that evaluates applicants on personal characteristics in six areas: knowledge and creativity, communication skills, teamwork, resilience, planning and organization, and ethics and integrity. Considering these personal characteristics alongside traditional metrics such as scores and grades is at the crux of holistic review, an approach to admissions that ADEA member schools have widely embraced in selecting their predoctoral students. In fact, according to a recent report by Urban Universities for HEALTH, a project that aims to increase health equity by diversifying the health care workforce, dental schools lead among the health professions in their use of holistic admissions.

ADEA began piloting the ETS PPI as part of the ADEA Postdoctoral Application Support Service (ADEA PASS℠) application in 2012, and program directors report that they like having a standardized tool to assess many of the variables linked to success in graduate, business or professional school. They also say the ETS PPI is becoming more helpful with each passing year, in no small measure because we have been working to clarify the instructions for employing the tool and encouraging faculty to make full use of the comment fields to fill in any gaps that may exist in a student’s letters of reference. These letters remain a vital part of every student’s application package, but they can be as varied as the individuals who write them. Moving forward, we will be working with deans and others to make sure that letters of evaluation are comprehensive and demonstrate a genuine knowledge of each student’s strengths and weaknesses to give candidates and program directors their best possible shot at finding matches that will work for them both.

Since the creation of ADEA/FADEA, the project has collaborated with the ADEA Council of Hospitals and Advanced Education Programs (ADEA COHAEP) to host two collaborative summits on advanced education admissions. The first summit allowed ADEA members to discuss the findings of the 2010 survey. The second, held in 2013, brought program representatives together to learn about new tools within the ADEA PASS application and gain a better understanding of how pass/fail dental schools evaluate their students. Seven of the eight schools that currently use pass/fail grading attended and shed light on the systems they have in place to distinguish outstanding students from good students in their academic environments.

The 2013 summit also touched on the use of multiple mini-interviews (MMI), the practice of having applicants work through short, structured problems with a series of faculty members. I first wrote about this technique in a 2008 issue of Charting Progress, which looked at ways of assessing student professionalism. Today, more schools and programs are using MMIs to reveal many of the characteristics that faculty most value. (For more on MMIs and other topics related to admissions, see the April 2014 Journal of Dental Education (JDE).)

Last fall I learned that some of our colleagues in medicine are using a proprietary online personality assessment tool to gather similar information in a slightly different way. Residency Select purports to reveal candidates’ behavioral attributes in three areas: usual tendencies, stress tendencies and drivers. Programs customize the instrument so that each candidate assessment profile reflects the program’s particular screening criteria. According to the company behind Residency Select, no dental residency programs are currently using the tool, but it is available to them. It will be interesting to see how this assessment instrument works for medical residency programs on some of our campuses and to consider whether it might be useful for some of our programs as well.

One group of programs that might welcome a tool of this type is oral and maxillofacial surgery (OMS) residencies. If you haven’t already guessed, OMS is the specialty that ranked academic talent highly in the 2010 ADEA/FADEA survey. In fact, this group of specialists placed academic talent at the top of their list and chose “National Board score above 90” as the fifth most desirable quality they sought in applicants. Why did the results for this specialty diverge so much from the findings for other groups of advanced education programs?

To find out, I called David Shafer, D.M.D., Associate Professor and Chair of the Division of Oral and Maxillofacial Surgery at the University of Connecticut School of Dental Medicine. Dave has been a member of COHAEP for more than a decade and is now the ADEA Board Director for Hospitals and Advanced Education Programs so he is well versed in the concerns of his peers. He is also in an unusual position. Situated in a school that uses pass/fail grading and in a specialty that values high-stakes standardized exams, he is willing to defend both.

“There’s no reason to suspect that at pass/fail schools, the students aren’t being taught to a very high level,” he told me when I asked about the reluctance of some programs to consider candidates from these institutions. “I’d argue that some of the pass/fail schools are some of the hardest schools in the country to get into.”

He also shared praise for the ETS PPI and its role in bringing more standardization to the appraisal of candidates. “We’ve had the PPI for three cycles now,” David observed, “and people are getting better at writing comments that are useful.”

But for some of the more competitive programs, Dave says that determining high academic achievement remains an important part of the mix. For his specialty in particular, strong exam scores are essential for entering the profession.

“The problem we run into in oral and maxillofacial surgery is that we need to know students can perform well on a high-stakes exam because they’re going to have to take other ones. Many of our students go on to get an M.D., which requires an ability to pass Step 1 and Step 2 of the Medical Boards, and then they have to take their oral maxillofacial surgery boards. I need that data. I need to know who can perform.”

To address this reality, OMS programs began requiring scores from the National Board of Medical Examiners Comprehensive Basic Science Examination (CBSE) when NBDE scores ceased to be available. The CBSE is considered a statistically valid, in-depth examination of basic medical science knowledge, and the test seems to be a good fit for these specialty programs.

As I wrote last month, the American Dental Association is developing an admissions test for advanced dental education programs in 2016. At a minimum, the exam will expand the admissions tools available to advanced education programs, but these programs are diverse, and one exam is unlikely to suit them all. Personally, I’m not concerned. Each year, dental schools manage to evaluate applicants from 1,800 different colleges and universities seeking admission to their predoctoral programs. If we can do that, I’m confident we will figure out graduate admissions in a pass/fail environment as well.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic begins a two-part consideration of the merits and challenges of pass/fail grading.

Although the number of pass/fail dental schools has remained fairly stable over the decades, the concept itself has gained renewed attention in recent years, most notably through the National Board Dental Examinations’ (NBDE) 2012 move to pass/fail grading for dentistry and dental hygiene licensure exams. While this switch has been generally well received, especially by students, the shift away from a graded exam has raised some questions. Chief among these are: How can advanced dental education programs best evaluate candidates in the absence of a numerical grade on a standardized exam? And, What are the implications of pass/fail board exams for students who count on high exam scores to gain entry into competitive programs?

This month, I want to examine these issues from the point of view of students, especially those attending pass/fail schools. Next month, I will take a deeper look at the concerns of advanced dental education programs and share some of the ways ADEA is assisting them in adapting to the new testing landscape.

Most of you will remember that the Joint Commission on National Dental Examinations (JCNDE) elected to move to a pass/fail grading system because of concerns about the misuse of exam scores and the security of the questions on the NBDE. The purpose of the NBDE is to help state boards determine whether individuals are qualified to obtain licenses to practice dentistry or dental hygiene. The JCNDE has made clear that the exams are not valid instruments for determining differences in knowledge and ability among test takers who score within the range of passing grades. Nevertheless, board scores were widely used in the past to screen candidates for admission to advanced education programs or even to rank predoctoral programs. By moving to pass/fail grading on the NBDE, the JCNDE put an end to the misapplication of scores for these alternate purposes.

As it happens, I attended one pass/fail school (University of Connecticut School of Dental Medicine) and later taught at another (Harvard School of Dental Medicine [HSDM]). At pass/fail schools, students receive numerical grades on their assignments just as they would elsewhere, and faculty average these to determine a grade for each course. The difference comes in how these grades are reported. Typically, schools set a cutoff for passing, and sometimes grades above a higher threshold receive an honors designation.

I didn’t consider each school’s grading policy when I decided where to attend dental school, and grading is not necessarily a paramount concern for students choosing schools today. But in talking with two students on the ADEA Council of Students, Residents and Fellows (ADEA COSRF) Administrative Board, I learned that grading does factor into the equation for some students when choosing where to earn their predoctoral degrees.

“It was one of the things I was most interested in when applying to dental school,” said Alex Brao, ADEA Board Director for Students, Residents and Fellows. “As a prehealth major in college, there was an overwhelming sense of everyone battling each other. There was never any camaraderie. People were always thinking, how much higher can my grade be?”

Alex is in his fourth year at the University of California, San Francisco, School of Dentistry (UCSF SOD), where he says he has found the teamwork and cooperative learning environment he was seeking. He has also found opportunities for recognition within the school’s pass/fail framework. “Everyone is good at different things—perio, prosthodontics, hand skills—so it is not always the same people earning honors,” Alex told me, and, he added, honors can be earned through initiative as well as through performance. Work in the community or leadership activities, such as participation in ADEA governance, can also garner honors recognition at UCSF SOD.

From my perspective, the pass/fail approach has a lot to recommend it. By eliminating the competition for class rank, pass/fail grading creates an environment that is conducive to learning rather than rote memorization. Exams are designed to assess each student’s competency rather than to assess students’ achievements relative to one another. When people talk about the downsides of pass/fail grading, I often hear others point to the need for students at pass/fail schools who want to pursue advanced dental education to find ways of distinguishing themselves in the absence of numerical grades.

Alex is applying to GPR programs and appears confident that he will gain admission, in part because UCSF SOD has an excellent record of placing its graduates. At the same time, he is sympathetic to the concerns of students who are applying to highly competitive specialty programs. “You can no longer go to someone and say, I have a 4.0 GPA and 200+ board scores,” Alex told me. “There are a lot more questions and fewer assurances. I can understand someone’s frustration.”

In 2012, a group of researchers at HSDM surveyed students to try to quantify the impact of the move to a pass/fail NBDE, and they presented their findings at the 2014 ADEA Annual Session & Exhibition. By a ratio of 3-to-1, survey respondents felt the move to pass/fail grading decreased their chances of getting into a specialty residency, and 80% wanted another objective measure to differentiate themselves to specialty program directors.

Cameron Reece, a fourth-year dental student at the Roseman University of Health Sciences College of Dental Medicine – South Jordan, Utah (Roseman CODM), is among those students who favor the creation of a new test designed specifically for graduate admissions purposes. Roseman CODM is one of eight dental schools that currently use pass/fail grading.

“I think something is needed—an exam or a standardized portfolio—to give us a way to show how good we are as students,” Cameron told me, and he believes a lot of Roseman CODM students share this view. Cameron was drawn to Roseman CODM by the school’s innovative curriculum and his belief that he would thrive in a pass/fail environment. He credits pass/fail grading with allowing him to focus his energies on learning and to achieve more than he would have otherwise. But he also feels that pass/fail grading puts him and his classmates at a disadvantage in applying to advanced dental education programs.

“A lot of people put a lot of stock into class rank,” he believes. “Graduating from a pass/fail school does affect which programs will look at you. Some programs have said they will not interview pass/fail applicants.”

Would the creation of a new exam address these concerns? Both Cameron and Alex told me that this question has become a perennial topic at ADEA COSRF meetings. Cameron would like to see proponents of a new exam advocate more strongly on behalf of this goal. Alex is less certain. “After all these meetings I’ve been to, I don’t know what the right answer is,” Alex confided. “I’m not in favor of more exams and more requirements, but I feel for the students who want to enter the specialty programs.”

While students and others deliberate this question, the American Dental Association is developing an admissions test for advanced dental education programs, which it expects to release in 2016. The precise scope of its content is still unclear, but the test will likely suit some programs better than others. It will be up to individual programs to decide whether or not the test will be a valuable admissions tool to add to those they already use.

Meanwhile, it’s important to remember why pass/fail systems emerged in the first place. They came about because most of us agree that (1) numerical grades are not necessarily reflective of the competencies needed to be a successful professional or resident, and (2) selection for advanced dental education programs should be based on additional qualities other than the ability to earn a high score on a high-stakes exam.

Pass/fail grading of courses and exams may indeed place new demands on students to find other ways to distinguish themselves from their peers, but I see a system that encourages students to take time for research, community service, leadership activities and the like, as all to the good. As Alex noted, the people who put forth the effort, succeed. “It takes a little bit more—externships, fellowships—but it makes them better applicants overall because they really know what it is they want to do.”

Developing the attributes graduate programs are seeking—commitment, compassion, leadership and teamwork skills—enriches students and, ultimately, the profession. Next month I will talk about the challenges that advanced dental education programs face in selecting the best candidates for their programs.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares the news from Barcelona, where dental educators from around the globe gathered to foster alliances and deliver leadership strategies that women can use to advance their careers and improve oral health.

Despite the presence of many familiar faces, September’s gathering in Barcelona was not your typical dental meeting. The 5th ADEA International Women’s Leadership Conference brought over 120 attendees from 17 countries to one of Spain’s most iconic cities to share their experiences and consider strategies for advancing women’s leadership in global academic dentistry.

Thirty-one ADEA member schools were represented by students, faculty, deans and other emerging and established leaders from academia, government and industry who made the trip from all four hemispheres to connect with colleagues. Men also took part, but the majority presence of women created an atmosphere in which most participants felt comfortable speaking about their concerns and seeking the support and mentorship they sometimes lack at home.

In an era when women are clearly visible in education, research and practice—not just in North America but on the world stage—some may wonder about the rationale behind such a meeting. After all, women will soon achieve parity in dental school enrollment in the United States, and the percentage of women serving as dental school deans in North America is higher than the percentage of women serving as medical school deans. Within ADEA’s leadership, half of our board members are women, including our Chair of the Board, Lily Garcia, D.D.S., M.S., FACP, so by many measures there has been tremendous progress.

Yet a closer look at the data—domestic and worldwide—reveals significant gender gaps within academic dentistry. Helen Whelton, B.D.S., Ph.D., M.S., F.D.S., Dean of the School of Dentistry at the University of Leeds in the United Kingdom, and President of the International Association for Dental Research, was among several presenters who shared data on women’s status in dental education and in academia generally. Among the most notable facts:

  • Women have achieved global parity at the entry level to higher education, but remain underrepresented in many places around the globe and in many academic disciplines.
  • Women are approaching 50% of U.S. dental and medical school enrollments.
  • In the United States, women hold about 35% of full-time and 30% of part-time faculty positions in dental education.
  • Within dental education, U.S. women earn about 82% of their male counterparts’ salaries. In the U.K., that figure is 88% when comparing the salaries of new graduates.
  • Women receive fewer research funding dollars, and they are less likely to be journal editors, principal investigators or members of research boards.

One of the most illuminating data displays at the conference was a slide illustrating how the presence of women and men changes as the level of education increases. Using European Union data, Helen pointed out that the lines on the graph are essentially parallel as women and men enter higher education and progress through the master’s degree, but the lines start to cross at the Ph.D. level. By the time they reach the level of professor, the lines have widely diverged, reflecting men’s 82% and women’s 18% shares of the professoriate.

Helen called this phenomenon the “academic career forceps” because the shape of the graph closely resembles the shape of this instrument. Whatever metaphor we use, closing the gender gap in academic dentistry won’t be easy. It will take a combination of external and internal pressures, and these will have to work in concert to allow the full potential of women’s leadership to be realized. Women can develop new attitudes and skills to propel their own careers, but changes in institutional policy and other external factors will also be needed to drive women’s advancement. And as this international gathering made abundantly clear, the levers for change will vary depending on context.

For example, in Spain, women now make up 45% of the dental profession, but private universities are graduating a plethora of professionals whom the market cannot absorb. In Nigeria, there are more women than men among the students and faculty in its dental schools. Tanzania, by contrast, has only one dental school, and women typically account for about 17% of higher education enrollment. India has seen gender equity increase dramatically for its educated class, yet cultural biases persist, and in the words of one panelist, educated women are on “a tightrope walk” trying to balance their masculine and feminine sides. In Saudi Arabia, funding for professional education is abundant, but segregated campuses and laws based on gender that restrict women’s mobility pose their own unique challenges when it comes to preparing women for dental practice.

The conference also revealed many commonalities among the experiences of the attendees. Several countries have documented that women’s working patterns differ from those of their male counterparts in dentistry. Women are more likely to work part-time, to take a career break and to retire before age 60, and women in Canada, New Zealand and the United Kingdom cited child care as the reason for these differences. Comments by Suhasini Nagda, B.D.S., M.D.S., FDS RCPF, Dean of Nair Hospital Dental College in Mumbai, India, suggest that this phenomenon exists in other countries as well. She reported that 87% of Indian women dentists agreed that childrearing responsibilities should be shared, and shared not only by spouses but by grandparents and the community as well.

Salary inequity was also on the minds of many participants. A lively Q&A on this topic followed one session, with panelists and attendees trying to tease out why salary differentials persist even in institutions with salary scales. Several speakers mentioned ADEA’s preconference webinar, Leaning In: A New Era of Women Leaders, which drew on Sheryl Sandberg’s bestselling book Lean In to explore strategies for career advancement. Others cited research from Harvard University and the Massachusetts Institute of Technology showing that women can be reluctant negotiators, and that their lower salaries are reflected in less academic achievement in other areas. Another study, conducted in Australia, found that men are willing to “hopscotch” from institution to institution in order to further their careers, whereas women are not.

Women face similar problems when it comes to research funding. American data on research funding also produce a forceps-shaped line graph, with women paralleling and even exceeding men as recipients of National Institutes of Health training dollars but dropping well below men when it comes to receiving research funding. Women apply less often, receive fewer research grants and publish fewer papers—key indicators for academic success.

These particular findings were conveyed by Kathryn (Kathy) Atchison, D.D.S., M.P.H., Vice Provost for New Collaborative Initiatives at the University of California, Los Angeles, and she suggested another way of looking at these data. It might be that current data collection, she posited, does not recognize the fact that “women still have other goals that are quite different from their male academic and dental colleagues.” Nevertheless, Kathy is ambitious when it comes to women’s leadership in dental education. In preparation for the meeting, she contacted her sister alums from the prestigious Hedwig van Ameringen Executive Leadership in Academic Medicine® Program for Women, better known as ELAM. (ADEA has partnered with ELAM to bring the benefits of this program to women in academic dentistry.) Their advice: “Recognize that there are many different opportunities for leadership. Don’t confine yourself to the dental school.”

Kathy urged conference attendees to consider aiming for positions in the university C-suite. She pointed out that while only 26.4% of U.S. college presidents are women today, almost all of them rose through the academic ranks. “So this is a possibility for everyone here,” she concluded.

For those who weren’t quite ready to make that leap, as well as for those who were, the conference offered concrete guidance for advancing any academic career. Advice included identifying mentors and sponsors, becoming active in professional associations and making strategic decisions about which academic service opportunities to pursue. The meeting ended with a skill-building workshop led by Judith Albino, Ph.D., President Emerita and Professor at the Colorado School of Public Health and AAL Senior Consultant. (Many of you know AAL as the organization with which ADEA has partnered to develop a variety of leadership development programs.) The session helped attendees recognize their strengths and gave them strategies for building on those strengths moving forward. I have no doubt everyone went home inspired by the experience of others and the connections they forged with colleagues from across the globe.

Of course, these events don’t happen without the support and hard work of many individuals. We have three ADEA corporate partners—Colgate-Palmolive Co., DENTSPLY International, Inc. and The Procter & Gamble Company—to acknowledge and thank for their commitment to providing support and sponsorship of the conference. I also want to thank all who served on the conference planning and advisory committees for making this event such a huge success. The local Faculty of Dentistry at the Universitat de Barcelona, whose representatives organized a private meeting with the mayor’s health secretary and a tour of the ornate city hall, deserves a special acknowledgement.

Finally, I want to recognize our own Jeanne Sinkford, D.D.S., Ph.D., ADEA’s Senior Scholar in Residence. A trailblazer in dental education, Jeanne first proposed the idea of an international conference to support the development of women’s leadership back in 1995. It is wonderful to see her idea come to life. Gatherings such as this can be instrumental in bringing forth the next generation of emerging leaders and in supporting change and innovation in dental education globally. ADEA is proud to have assisted at the birth of a global conversation that is sure to continue in the years ahead.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic explains why community water fluoridation—a public health intervention most of us take for granted—is under attack as never before.

It has been called one of the 10 great public health achievements of the 20th century, yet 70 years after its introduction in the United States, community water fluoridation can no longer be taken for granted. Opponents of fluoridation continue to advocate for the removal of fluoride from water supplies, and they have found some interesting allies.

Just this past summer, Israel’s Health Minister Yael German ended a decades-long government policy that mandated public water fluoridation in communities of 5,000 or more inhabitants. This occurred despite vocal opposition from the Israeli Dental Association, the academic community, public health experts and the country’s Prime Minister, Benjamin Netanyahu. German acknowledged that fluoride is beneficial in preventing dental caries but defended her actions on the grounds that she believes fluoride may be harmful to certain groups and that administering it through the water system infringes on personal rights.

I’m sure I don’t need to tell any of you of the massive amount of credible scientific evidence that has demonstrated again and again that optimally fluoridated water is safe to drink, does not cause systemic disease and provides the best protection against dental caries in both children and adults over the course of a lifetime. Dental fluorosis, a change in the appearance of tooth enamel that does not endanger health, is the only proven outcome associated with ingesting too much fluoride. Severe fluorosis rarely occurs in communities where the amount of fluoride in the water is in keeping with the standards set by the Centers for Disease Control and Prevention (CDC).

Despite this strong body of research, opponents of fluoridation assert that fluoride is linked to health problems ranging from cancer to diabetes to thyroid disease. Recently, they have touted the findings of a study published in 2012 in Environmental Health Perspectives to support their call for eliminating water fluoridation. The study is a systematic review and meta-analysis of the possible effects of fluoride on children’s neurodevelopment. The authors found that “children in high-fluoride areas had significantly lower IQ scores than those who lived in low-fluoride areas,” and concluded that these “results support the possibility of an adverse effect of high fluoride exposure on children’s neurodevelopment.”

It’s important to note that the children in question did not reside in New York, Ontario, Jerusalem or other places where fluoride was added to the water at ratios considered optimal for improving oral health. The vast majority of the data in the reviewed studies came from China, where considerably higher levels of fluoride occur naturally in the drinking water of many communities. As the authors of the paper point out, the exposed groups in the studies they reviewed had access to drinking water with fluoride concentrations up to 11.5 milligrams per liter, so in many cases, fluoride concentrations exceeded the levels recommended in the United States for improving oral health (0.7–1.2 milligrams per liter) or allowed by the Environmental Protection Agency (4.0 milligrams per liter).

Nevertheless, anti-fluoridation activists seized on the paper as evidence against community water fluoridation, and they used the Harvard affiliation of the paper’s lead author, a research scientist in the university’s School of Public Health, to bolster the credibility of their cause. These misrepresentations of the paper’s findings led the Dean of the Harvard School of Dental Medicine, Bruce Donoff, D.M.D., M.D., and the Dean of the Faculty of Medicine at the Harvard Medical School, Jeffrey Flier, M.D., to issue a letter in 2013 expressing their support for community water fluoridation and pointing out the “numerous reputable studies” reinforcing its safety and efficacy.

Setting the record straight is essential and will require an energetic response from all of us who are in a position to make scientific evidence easy to understand for the public at large. A report in the Journal of the Massachusetts Dental Society found that opponents of community water fluoridation dominate Internet and social media discussions of the topic. Moreover, some research suggests than many Americans are inclined to believe in medical conspiracy theories in general.

In a letter to JAMA Internal Medicine published earlier this year, two political scientists from the University of Chicago reported that 12% of Americans agree with this statement: “Public water fluoridation is really just a secret way for chemical companies to dump the dangerous byproducts of phosphate mines into the environment.” Perhaps more disturbing, fewer than half of respondents disagreed with the statement, which means there is an urgent need to steer people toward reliable sources of accurate information so they can play an informed role in decision-making around this crucial aspect of the public health infrastructure.

The CDC is an excellent place to start. The agency’s Community Water Fluoridation FAQs explain how fluoride works when added to drinking water and topical products such as toothpaste, and discuss the potential adverse effects from overexposure in clear and unbiased terms. Another Department of Health and Human Services site, the Guide to Community Preventive Services, has links to a 2013 systematic review of the evidence on which it bases its support of community water fluoridation as well as a summary of the rationale for supporting the intervention. The Campaign for Dental Health, a program of the American Academy of Pediatrics, has developed guides for health professionals on fluoride safety and guides for consumers and patients as well.

These resources provide plenty of evidence to counter the misinformation circulating about fluoride, but they do little to blunt the argument that community water fluoridation deprives individuals of their freedom to decide whether or not they want to use fluoride to protect their teeth. The Fluoride Action Network (FAN), the leading advocacy group opposed to fluoridation, quotes one of its congressional supporters, Rep. Dana Rohrabacher (R-CA): “[I]n this country, we should be the ones who should be deciding what we put into our bodies one way or the other. Not the federal government or the local government putting fluoride into our water. A lot of those things come down to freedom issues. They come down to whether or not we will control our own destiny.”

This type of rhetoric is reminiscent of the culture wars that have divided Americans around other issues related to health. Last month, public television’s premier science program, NOVA, devoted an hour-long show to the shift in attitudes toward vaccination that has led to recent outbreaks of measles and pertussis—diseases that were so well controlled in North America that physicians had difficulty believing what they were seeing when the first 21st-century cases appeared.

The rise in dental disease that follows the cessation of water fluoridation is harder to spot than a sudden outbreak of highly contagious disease, but it is visible nonetheless to those who know where to look. In Calgary, Alberta, where the City Council voted to stop fluoridating the drinking water in 2011, dentists say they have already seen a noticeable increase in the severity of dental caries in their patients’ teeth.

It may take a few years before we see the impact of the recent decision by the Israeli Ministry of Health. (The new policy does not ban fluoridation despite what some headlines might suggest, just makes it optional.) Moving forward, the ministry plans to address the oral health needs of the public by instituting a number of health promotion programs. These are aimed at educating pregnant women, parents, preschool teachers, health care providers and school-age children about oral health.

These types of efforts are all to the good, but researchers have found that they are neither as effective nor as affordable as community water fluoridation when it comes to decreasing the prevalence and severity of dental caries. Importantly, community water fluoridation is also a powerful strategy for eliminating oral health disparities. As the CDC stated in hailing the practice as a public health success, “Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.”

Last month, FAN held its first lobby day in Washington, D.C., and called on Congress to hold joint congressional hearings on water fluoridation. FAN wants Congress to stop spending taxpayer money to promote fluoridation through the CDC. FAN would also like the Food and Drug Administration to regulate ingested fluoride as a drug, and the Environmental Protection Agency to reevaluate its standard for the maximum allowable level of fluoride in drinking water.

While opponents and proponents of community water fluoridation may disagree on what constitutes the best available scientific evidence, it is worth noting that we share a mutual concern about the health of future generations and a desire to see science guide public health decision-making. It is up to those of us in the academic dental community to continue contributing to and disseminating solid research. Through our contact with patients, we also have an opportunity to educate the public at large about the overall benefits of fluoride and water fluoridation specifically. This may be at least one effective way to help put public fears to rest.

Today, three quarters of U.S. communities—with the notable exception of Portland, Oregon, whose citizens voted once again to prohibit fluoridation of the city’s drinking water in 2013—provide residents with fluoridated water, as do all major U.S. cities. About 45% of Canadians have access to fluoridated water, but regional variations are significant.

ADEA supports and encourages fluoridation of community water supplies and the use of topical fluoride. So do the American Dental Association, the International Association of Dental Research, the National Institute of Dental and Craniofacial Research and the World Health Organization.

Former U.S. Surgeon General Dr. C. Everett Koop once said, “I encourage the dental profession in communities which do not enjoy the benefits of an optimally fluoridated drinking water supply to exercise effective leadership in bringing the concentration to within an optimum level.” Today he might say that dental professionals in all communities need to lead on this issue. I know that ADEA members will be in the vanguard.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic explains why dental schools need to take a serious look at whether they are adequately preparing students to apply genetics in clinical care.

Leave a comment at the new Charting Progress.

Ready or Not, the Era of Personalized Dentistry Is Here

30,000. That’s the estimated number of people in the United States whose genomes had been sequenced as of 2011. I am not one of them, but I have an interesting related story to tell. Five years ago, I attended the annual TedMed gathering in San Diego. There I heard a presentation from Anne Wojcicki, the founder of 23andMe, a privately held personal genomics company whose direct-to-consumer personal genome test was named Invention of the Year by Time magazine in 2008. The company offered attendees at the meeting analysis of their DNA. I accepted out of idle curiosity, and since then, I’ve gained a sneak peek into the era of personalized medicine—and personalized dentistry—that lies ahead.

In 2003, the Human Genome Project completed its map of the full sequence of genes that make up the human genome. This knowledge and subsequent discoveries have deepened our understanding of what causes diseases and given us new insights into treating diseases and avenues for preventing them prior to their onset.

Today the ready availability of genetic testing and genome sequencing, and their relative affordability, have brought genetic knowledge into the clinical arena, allowing physicians and dentists to personalize the care they provide to individual patients. It doesn’t take much imagination to envision how knowing about the gene variants that affect the function of a particular patient’s pain receptors and analgesic absorption could be useful in a dental office. Taken a step further, it is easy to see how the clinical application of genetics is on the cusp of transforming care.

Ten years ago, Francis Collins, M.D., Ph.D., then Director of the National Human Genome Research Institute, and Larry Tabak, D.D.S., Ph. D., then Director of the National Institute of Dental and Craniofacial Research, published a paper calling for increased genetics education for dental health professionals. Why? “Because education is about the future, not the past, and we are now entering the era in which genetics and genomics will play a vital role in both oral health research and dental practice,” they answered.

The Collins and Tabak paper speaks of salivary diagnostics, salivary gland gene transfer, tissue engineering and the use of stem cells as just a few of the scientific advances that need to be incorporated into dental education so that genomic research outcomes can be translated into improved clinical outcomes for patients. Since then, a decade of new discoveries related to the architecture, function and coding of human genes makes this call all the more urgent. Until recently, genetics was an area of interest for a few, but it won’t be long before all dentists will need to be versed in human genetics if they want to continue to provide high-quality care. (For more on this topic, see a recent guest editorial by Hal Slavkin, D.D.S., Professor Emeritus and Dean Emeritus at the Herman Ostrow School of Dentistry at the University of Southern California, in The Journal of the American Dental Association.)

A 2001 survey conducted by Tom Hart, D.D.S., Ph.D., and researchers at the University of Pittsburgh revealed that only eight dental schools provided a formal course in human genetics at that time, and most of the remaining schools did not have plans to create one. These institutions reported that genetics education was integrated into courses such as pathology, biochemistry and microbiology, with considerable variation in the amount of time devoted to genetics and the topics each school covered.

When I spoke to Tom earlier this month, he told me he suspects there may be even fewer stand-alone courses in human genetics at dental schools today. “Those courses often came about because of the passion of individual faculty members,” he told me, “and some of them have since retired.”

Tom, who is currently a Professor at the University of Illinois at Chicago College of Dentistry, is one of three dentists serving on the Inter-Society Coordinating Committee for Practitioner Education in Genomics, more commonly referred to as ISCC. The committee is charged with improving the genomic literacy of physicians and other healthcare providers and enhancing the effective use of individual patients’ genomic results in their clinical care. The means to this end is the development and sharing of educational competencies and resources that professional societies, specialty boards and others—including associations such as our own—can modify to support the educational needs of their members.

Karen Novak, D.D.S., M.S., Ph.D., is representing ADEA on the ISCC. Karen is Associate Dean for Professional Development and Faculty Affairs at The University of Texas School of Dentistry at Houston where a genetic counselor is working with others at the dental school to assess genetic content in the current curriculum and propose ways to better integrate the topic so it has relevance for the type of personalized clinical care graduates will soon be expected to provide.

One of ISCC’s stated goals is to collaborate with provider education groups to “standardize approaches, competencies, and knowledge base for all health workers.” While the committee’s mandate is to improve genetic literacy of the practice community, ADEA is committed to seeing that the committee’s work also benefits the education community so, as Karen put it, we’re not playing catch up. I am grateful for the way in which Karen is representing all of us on this committee.

This federal initiative is occurring none too soon. According to an article that appeared earlier this summer in the New England Journal of Medicine, several thousand physicians have already ordered clinical genome sequencing or its less expensive abridged version, exome sequencing, for their patients. The paper’s authors anticipate that about 10,000 of these tests will be ordered in 2014, and that the number will only grow as the cost continues to decrease dramatically. The consumer demand will also broaden from individuals with difficult to diagnose conditions to healthy individuals who are curious about their genetic risk factors, ushering in the use of genomic information for preventive as well as diagnostics purposes. As Tom put it, “Today, the problem is not acquiring genetic information, but what to do with it.”

Dental educators are not immune to this problem of appropriately handling genetic information. Tim Wright, D.D.S., M.S., Director of Strategic Initiatives at the University of North Carolina at Chapel Hill School of Dentistry, has a longstanding interest in genetics and represents the American Association for Dental Research on the ISCC. Tim and I both attended dental school in the 1970s, before the field of genetics came into being. While it is increasingly obvious that all health professionals who diagnose and treat disease will need a grounding in this science, Tim fears that most dental educators are disinterested in genetics and ill prepared to help their students gain competency in this area. He sees faculty development as an essential first step.

“Faculty need to know about the clinical implications of genetics, why it is important in terms of cancer predisposition, oral craniofacial anomalies, or to be a good diagnostician,” Tim told me. “Most dental schools don’t even teach how to do a good family history. That’s a key component as a foundation for genetics, and it’s going to be critical for helping our patients achieve optimal health.”

I agree. If dentists and dental educators don’t become schooled in this area, the risks could be substantial for our patients and our practices. We need to know when genetic testing does and does not have value for clinical care, and we need to understand the legal and ethical dimensions that come into play when the information revealed by testing could have health implications for an individual’s entire family. Meanwhile, professional societies representing geneticists have voiced serious concerns about the potential harms that may accrue from the commercialization of genetic testing and its marketing to healthy individuals. Not only is the quality of the testing at issue—how the results are interpreted is also a concern. If a finding shows a 50% increase in a risk factor for a specific condition, a clinician will convey that information differently depending on whether the original risk was 2% or 60%, but will a testing company do that? We will have to wait and see.

“Regulation of genetic testing is not what dentists believe it to be,” Tom Hart told me. “Tests are not necessarily clinically valid or clinically useful. That’s my greatest concern—this lack of understanding—and it won’t go away until we have comprehensive genetics education at dental schools.”

Tom is optimistic that ISCC can start to remedy this situation. He has confidence in the group’s leadership and sees dentistry’s participation as a tremendous opportunity to be at the table with a truly interprofessional group of scientists and healthcare providers whose work will help translate genetics into clinical care. He believes this inclusive approach will go a long way to circumvent problems for patients by reducing disparities in the way different clinical disciplines use genetic information.

Tim Wright is equally enthusiastic about the interprofessional makeup of the ISCC and the resources it is creating. The group is building competencies that each discipline can adapt and creating resources, including a bank of unfolding case studies that educators can use in their classrooms. But Tim cautions that the ISCC will only be part of the solution.

“There is currently no funding for it,” he points out. “It’s a voluntary effort, and if it’s all just people like myself, each putting in one scenario, it’s probably not going to be as robust a national resource as it could be.”

Tim points out that curriculum revision is not a small or insignificant task, especially when most faculty are not versed in the subject matter and the geneticists who are, are focused on research. He suggests that the Commission on Dental Accreditation standards for predoctoral dental education be used to move the ball forward. “It would be very helpful to have the word ‘genetics’ in there,” he observes. “That is what drives institutions to say, this is important and we need to do it.”

Meanwhile, ADEA stands to gain from participating in the ISCC. In addition to sharing and helping to develop resources, we are learning how the healthcare professions can collaborate to optimize health care through a shared understanding of the issues that impact health across our professions and disciplines. And we also have talent and resources of our own to bring to the table, starting with the report of the 2007 Josiah Macy Jr. Foundation study on genetics and its implications for education and practice.

So how has the advent of personalized medicine affected me? The fortunes of 23andMe changed last year, and the company currently offers only ancestry-related information derived from its DNA analysis for new customers. But for those of us who got in on the ground floor, the company continues to send regular updates on breakthroughs in genetic knowledge that might be relevant to our health. I have yet to share this knowledge with my healthcare team, but under the right circumstances I will, and those circumstances could arise at any time. New knowledge of human genetics is created every day, revolutionizing our understanding of diseases, their treatments and ourselves. It’s not too soon to prepare for this future.


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