The average debt of a graduating orthodontist is about $250,000, but for some the figure exceeds $600,000. Depending on interest rates, these young orthodontists will pay thousands of dollars a month for 30 years or more just to service the debt. Most educational debt cannot be cancelled by bankruptcy. In the current economy, many recent graduates are struggling to find professional opportunities that are adequate to service their debt and support a desirable lifestyle. Fewer orthodontists have adequate resources to retire, many practices no longer have the patient volume to support an associate, and high debt makes a new graduate a poor risk for a loan to purchase a practice.
The present climate of tight credit will probably continue for some time because lenders are well aware of the financial decline of many practices and are factoring in the projected impact of automated orthodontic technology, which is rapidly advancing for both removable and fixed appliances. CAD-CAM methods produce a customized appliance that can obtain an “adequate result” with less clinical effort. Doctors offering automated services might find it difficult to pass on the increased costs to the patient, so, with a decreased margin per patient, the only way to maintain practice income is to increase patient volume. With effective marketing, a clinician (orthodontist or other) will probably manage several times the patient load of the average solo practice. A more traditional, low-volume, high-quality practice requires a high degree of clinical skill to be competitive and control costs.
There continues to be a need and desire for orthodontic services, but the ability to afford treatment has diminished for several reasons: (1) a high unemployment rate that will probably persist for years, (2) a dramatic loss of high-paying manufacturing and construction jobs, (3) increased costs of medical care, and (4) higher birth rates among economically disadvantaged parents, including unmarried women. The decreased pool of patients who can afford elective services is negatively impacting all of dentistry, encouraging general practitioners to provide orthodontics services or employ part-time orthodontists at minimal compensation, rather than referring to an outside specialist.
Many struggling, highly indebted practitioners are destined to wonder whether their graduate orthodontic education was a good investment. This should be a wake-up call for not only orthodontic educators but also our entire specialty. Students and new graduates are our lifeblood. Increasingly, orthodontic specialty training is fueled by student debt, and providing the education can be a lucrative business, because of high tuition and clinical income and fees. New orthodontics programs continue to start, and many existing programs are increasing their class sizes, even as their graduates are struggling to find adequate professional opportunities. There is still an adequate supply of students (domestic and foreign) who are willing to assume high debt. Lenders believe that students are a good risk, particularly because they are mortgaging their professional career, but how much more debt can students endure?
Educators have little control over the applicant pool, class size, tuition, or the demand for specialty training. However, they can ensure that students master the essential clinical skills required to be competitive. The students are paying dearly for a high-quality education, and it is important that all of them get it. Unfortunately, current accreditation standards for orthodontic clinical competency can be interpreted in almost any manner that an institution, its administration, or faculty desires. Over my career in orthodontic education, I have focused on evaluating the didactic and clinical skills of students and recent graduates as (1) professor, (2) clinical investigator, (3) accreditation site visitor, (4) external program appraiser, (5) mock-board examiner, (6) American Board of Orthodontics (ABO) clinical examiner, and (7) annual observer of the College of Diplomates of the ABO case display.
In recent years, I have noted a progressive incidence of undesirable clinical outcomes that I believe reflect a less-than-optimal education. However, there is a bright spot. Students graduating from programs emphasizing the ABO Initial Certification Requirements (ICE) are routinely achieving superior clinical outcomes. I have asked many of these impressive young clinicians about the importance of their ICE cases. They believe that the educational value is the clinical rigor associated with selecting qualifying cases, using specific mechanics to obtain an optimal result, scoring the final alignment to quantify deficiencies, and then documenting the treatment cephalometrically. Routinely, they report learning the most from their 6 ICE patients.
The American Association of Orthodontists (AAO) can help by offering financial counseling, providing low-interest loans through the proposed credit union, and establishing a fund to partially guarantee student-loan defaults. The credit union is a helpful long-term solution, but a loan-guarantee fund could have a dramatic impact immediately. Most orthodontic students exceed the limit for federally guaranteed loans during dental school and must finance their graduate training with higher-interest private loans. If the specialty (AAO, AAO Foundation, and industry) provided a fund to partially underwrite student-loan defaults, the risks to lenders are reduced, and lower interest rates can be negotiated. Even a 1% reduction in the interest rate on a large loan is huge benefit. In return, these borrowers must be members of the AAO, ensuring that financially challenged practitioners stay engaged with the specialty.
With respect to the student-debt problem, there is plenty of blame to go around. Educational costs increased at a rate greatly exceeding inflation, institutions encouraged students to borrow heavily to pay tuition, some lenders were predatory, and many students were irresponsible borrowers. Institutions, educators, and the AAO have done little to help. We must collectively provide the clinical skills and financial support to ensure that the education was worth the debt!