An Historical Time Line... cont'd

by Dr. Larry White

The April 2001 issue of the American Journal of Orthodontics carried an historical time line that highlighted some of the notable achievements of the American Association of Orthodontists over the past century. Time tends to erase some memories and one forgets that the profession hasn't always had among other things air turbine handpieces, the American Board of Orthodontists or an executive secretary of the AAO.

Another development that occurred in 1970 was the dissolution of the orthodontic preceptorship program, which the AAO formally endorsed in 1940s. This orthodontic training program allowed dentists to apprentice with an established AAO member for three years and then establish their own specialty credentials by passing an examination. By 1970, pressure from the AAO to consolidate and balance orthodontic training placed all sanctioned training in university programs.

On the surface, this change seemed as innocuous as it was well meaning, but nothing altered orthodontics quite like this one change because it essentially turned over the future of orthodontics to the universities of the United States. From this point on, they would essentially determine the direction of the profession. Universities and their faculties would decide who was admitted, how many were admitted, the curricula taught, the hours devoted to research, the amount of clinical experience, the time spent in the programs and so forth. The AAO, through its House of Delegates, has some input, but it is minimal at best so as not to interfere with the autonomy and discretion of the individual institutions that manage these programs.

How has this assignment of duty worked? For the most part reasonably well, but recently the custodians of this charge have been telling the AAO that a crisis in orthodontic education now exists. Currently, at least 10 chairs of orthodontic programs lie vacant. Approximately 100 full-time positions remain unfilled in orthodontic departments. Were it not for the unselfishness of part-time faculty in our universities, many of the orthodontic programs would undoubtedly have to close. With this much dilution of faculty, it is hard to see how the current orthodontic education scheme can remain healthy and viable. The crisis as I briefly experienced it has three aspects: personnel, purses, and product.

Most universities complain that they cannot compete for personnel because of low salaries, which their institutions dictate; but this is only partly true. The schools do have salary caps that cannot be easily violated. Yet many of the schools severely limit what their faculties are able to earn outside of their university employment. Some insist that the faculty engage in an inefficient and highly limited intramural practice as the only supplement to their salary. They forbid any independent outside practice.

Also more and more schools are insisting that Chairs come with Ph.D. degrees. And not just the degrees but also the obligatory NIH research grants that they are supposed to collect with those degrees. In fact, the pursuit of federal grants has become such a priority for full-time faculty that it has relegated the teaching of orthodontics to a secondary status.

Another barrier that has arisen even for people who do get their advanced doctorates has been the recent tendency of schools to give tenure only to those who publish in highly ranked journals. Not one of the orthodontic journals worldwide is ranked in the upper 1st or 2nd tiers of publications, which universities recognize. This means that orthodontic Ph.D.s will need to publish in fields completely outside of orthodontics, which dictates that their stay in academia will be prescribed by disciplines that hold no esteem for orthodontics. I have a friend who is a first-rate orthodontic researcher, teacher, clinician and frequent publisher whose tenure was denied in this senseless way.

A Ph.D. may better prepare people for a research career, but it can hardly confer extended clinical knowledge. But deans of dental schools increasingly endorse this personnel approach. In some instances, we now have the scandal of even non-dentists being made chairs of orthodontic departments, which de-emphasizes clinical features even more. Additionally, only a little over 50% of all the orthodontic chairs in American schools are members of the American Board of Orthodontics. While the ABO is not necessarily the sine qua non of orthodontics, it does indicate at least a minimum of interest in clinical skills and knowledge. Such decisions are almost always left up to the deans of the institutions, so if there is a personnel crisis in orthodontic education, it is self-inflicted, and we have to look no further than to the leadership of our schools.

Deans who have taken a pragmatic approach to this problem have little or no problem in faculty recruitment. The University of Pacific comes to mind as an institution that allows faculty to have independent practices, so their teachers are able to do about as well financially with their part-time practices and full-time professorships as they would do in a full-time orthodontic practice.

Those who wish to teach full-time should not be financially punished because of their appetite for academia. Yet, that is exactly what happens for the most part in many orthodontic departments right now. Many potential professors simply decide that they can't afford to teach full-time with all of the institutional restrictions on their earning power. Who can blame them? One's family should not suffer because of an inclination to instruct. Nevertheless, if these people could supplement inadequate organizational salaries with outside work, many more would be willing to make that tradeoff and the so-called personnel crisis in orthodontic education would abate.

A second feature of this crisis in orthodontic education that is closely related to the personnel issue concerns the purse or the economics of running orthodontic departments. Traditionally, orthodontic departments have been substantial profit-centers for dental schools - so much so that incomes from their enterprises are often diverted to shore up the less profitable departments. Whatever the merits of such administrative decisions, and they are often compelling, the net effect has been to dilute and limit the resources of orthodontic faculties and to place their programs in jeopardy.

It is no accident that the most successful and well-regarded orthodontic departments are those whose chairs have proven worthy of keeping and employing major amounts of their departments' incomes.

I am not sure how all of this school-wide dependence on orthodontic departments developed, but right now it is almost universal. Without the income generated by orthodontic departments, many schools' entire curricula would be endangered. My suspicion is that as the sponsors of schools such as state legislatures continued to squeeze budgets, deans began to scramble to find funds wherever they existed.

Nevertheless, this is an unsustainable economic situation. Institutions must decide if they really want graduate departments of orthodontics and properly fund them or they need to shut them down.

The final feature of this crisis is the product of our schools or the graduates. Of the 300 orthodontic residents who graduate each year, 100 of them are foreign-born, and they return to their homelands. That leaves only 200 to replace the 300 - 500 orthodontists who now retire each year. This is occurring while the demand for orthodontic services continues to grow. Although orthodontists may feel that a shortage of competition is a good thing, they should not expect the public, the federal and state governments to feel the same way. They have a history of intervening and regulating professions and industries in ways that are not always beneficial to all of the parties.

One solution might be to limit the number of foreign admissions and thereby increase the volume of orthodontists who will stay and practice in the U. S. There is certainly no lack of qualified American candidates for those 100 positions that are now taken by foreign students. At one time there were no alternative training centers for people from other countries, but at this point practically every nation in the free world has some first-rate programs. The presence of foreign orthodontists has certainly enriched orthodontic departments and has extended the influence of America throughout the profession worldwide, but ultimately, the first priority of American universities is to serve its own citizens, and right now we are in danger of not doing that.

Almost all of the early university orthodontic programs were two-year events, and the ADA approved curriculum is still designed for two years. But within the past decade, more universities have extended their orthodontic curricula to three years. The justification for this lengthening has been to allow residents to complete meaningful research, gather master degrees and defend their theses. There are several pros and cons regarding this lengthening of orthodontic training. Nevertheless, one indisputable effect has been to retard the provision of orthodontists to the public.

Until recently no one had even studied, much less discovered, if this extra year of training actually benefits residents. For instance, do three-year residents become ABO Diplomates more often than two-year residents do? Do they make more faithful alumni and/or society members? Do they engage in study clubs more frequently? Do they publish more professional papers? Do they finish treatments more thoroughly? A study now completed at LSU shows that there are no measurable differences in two-year graduates and those of three years. So we may be doing the residents and the public a disservice by insisting on a third year.

All of the proceeding has been said to preface the flashback, which the AJO historical time line encouraged in my own mind. Many of the best and most contributive orthodontists I have known during my professional life have been those trained in preceptor programs, e.g., Reed Holdaway, Charles Tweed, Tom Creekmore, Homer Phillips, Tom Matthews, Jim Reynolds, Birte Melsen, Giorgi Fiorelli, etc. I don't think anyone would ever question the competency, contributions or dedication of these people. Could we possibly create these kinds of people again with preceptor programs? Maybe it is time to take another look at the preceptor program as a way of supplementing our university programs to relieve the current orthodontist shortage, which will only grow in the near future.

I feel confidant that the AAO and ADA methods of accrediting university programs could be easily adapted for orthodontic preceptor training programs. The unevenness of education in the previous program was due to a poor-vetting technique for the participating doctors. Accreditation groups could solve this problem by approving only doctors who meet specially developed criteria for preceptor training and enforcing that standard much as they now do for institutions. Orthodontists who wished to retire could qualify to accept and train a preceptor within this program.

The lesson from all of this is that the profession cannot afford to continue down the same path that has led us to this crisis. Somewhere we need to get back on a track that will allow us serve our members, residents and the public at large in an exemplary manner.