Now that I am 18 months into my academic retirement, I thought it would be a good time to reflect on graduate orthodontic education. I spent 4 decades teaching in the graduate orthodontic department at the University of Washington (UW); although my comments reflect the UW experience, I think they will provide insights on graduate orthodontic education in general. To provide some objectivity, I sent a nonscientific questionnaire to 1 member of each class from 1995 to 2014. I selected students somewhat randomly but tried to obtain adequate female representation and what I perceived were residents from different socioeconomic backgrounds. I asked 7 questions. I will summarize their responses, quote from some, and add a few personal observations.
When you finished the program, did you feel that you were prepared for private practice? If not, where were the deficiencies?
Everyone felt well prepared in the areas of diagnosis and treatment planning.
“I felt I had a very strong foundation in diagnosis and treatment planning. I felt confident in managing complex orthodontic cases, and I knew how and where to research treatment challenges when they arose.”
“I feel the program helped develop my treatment planning skills for all types of cases. In addition, the program did a fantastic job teaching critical evaluation of finished cases.”
“I can’t emphasize enough how prepared I felt to treatment plan cases effectively.”
One person, however, noted, “I wish I were also prepared for compromised treatment modalities, as many patients do not agree to ideal treatment plans.”
I believe the respondents’ perceived strength in diagnosis and treatment planning comes from the breadth and depth of the clinical faculty and the seminars that precede each clinic session. There are 3 instructors for each of the 6 weekly clinical sessions, and no instructor has responsibility for more than 1 clinic; the residents are exposed to 18 clinical faculty members on a regular basis. The seminars are generally split between student presentations (treatment planning, analysis of progress, or final records) and faculty presentations. Most faculty presentations use the following model: presentation of original records; establishment of a problem list; discussion of advantages and disadvantages of all reasonable treatment options, including no treatment; and finally, analysis of posttreatment records. As would be expected, faculty members tend to show challenging and well-finished cases. Some residents commented that they would also like to see presentations of cases for which the results were less than ideal, regardless of the reason.
The most common program weakness was the lack of education in practice management. Most graduates did not feel capable of running an office.
“I felt utterly unprepared for the business side of practice.”
A number of former students said that they least enjoyed the business side of practicing orthodontics. A graduate from 1995 commented, “To this day, the most frustrating aspects of my day are all of the business issues of running an office.”
Over the last few decades, the professional environment has changed. Private practitioners compete with corporate practices for patients. Banks are less likely to make loans to recent graduates, especially those already saddled with educational debt, and the government regulatory environment is so much more pervasive. I believe that the goal of educating orthodontists for clinical practice necessitates a greater focus on practice management. In recent years, the UW has included special seminars in practice management, organized by a clinical faculty member. In 2015, a practice management course will become part of the core curriculum. Also under consideration are externships, where a third-year student would spend 1 or 2 weeks in the office of a practicing faculty member.
What were the strengths of the program? What were the weaknesses?
All respondents cited the strengths of the faculty.
“Great mentors with real-world practice experience.” There was a “commitment to our profession that was contagious and inspired us.”
Other strengths included “an evidence-based treatment philosophy,” “a strong foundation in diagnosis and treatment planning,” “a collegial environment that encouraged curiosity,” and “tremendous research support.”
Noted weaknesses included not keeping up with technology and not starting patients early enough to finish them by the end of the program. Other weaknesses included the lack of coordination between the part-time clinical instructors to ensure that all relevant clinical procedures had been covered and the reliance on older “siblings” to teach and guide.
Is there value in requiring research?
Despite a few comments about spending too much time on research, there was unanimity about its value.
“Yes. I think it is essential to the profession and the students. Some of our best orthodontic research has been conducted by or done in conjunction with orthodontic residents. It also forces students to think very critically about research design, statistics, etc., so that they can better analyze publications for the benefit of their patients.”
“From the first committee meeting to thesis day, it was an intense, involved process. It was a lot of work, but I think that if you are going to be a part of this profession, you should contribute to orthodontic research.”
“I think the greatest value in requiring research is so that one may be able to ascertain the quality of others’ research.”
Were you in debt when you finished the program? If so, did it affect your professional opportunities or career path?
Although educational debt has become a greater issue for each class, it is not a new problem. Students from 20 years ago dealt with this problem. Some residents left the program with no debt, usually because of financial help from their families, and some left with enough debt to affect their short-term career choices. No resident with a substantial debt started a practice. They either found employment in corporate dentistry or associated with an established orthodontist. The following is a representative comment.
“I finished UW with about $180,000 of debt. At the time, it seemed like a lot of debt, but not necessarily compared to today’s residents! Due to my debt, I certainly felt pressure to get a job with steady income when I graduated. I considered starting my own private practice, but debt was 1 factor that steered me away from that path. I did end up working for a small ‘corporate dentistry’ type of operation for my first 2 years. It was not going to be a long-term situation, but it did pay the bills. It also allowed me the time to search for the ideal type of practice that I would want to associate with, partner with, or buy out.”
How are you keeping up with changes in orthodontics? How are you staying on “top of your game”?
As expected, the answers varied: perusal of the AJO-DO , meetings, continuing education courses, Orthotown, study clubs, and teaching. More recent graduates tend to have a network of classmates and colleagues with whom they electronically share records for discussion.
Have you become ABO certified? If so, why? If not, why not?
About half of the respondents are ABO certified. Those who thought that it was an asset said “that turned out to be one of my greatest learning experiences. In residency, mostly successful cases are shown. I learned the most from my cases that were not of ABO quality.”
“I feel it was a very important step in my career. It is a great learning opportunity! I feel I am a better orthodontist because of it.”
Others were ambivalent or negative.
“I just feel like board certification is something that we ‘should’ do, although I see marginal objective benefits.”
“Yes, but I did not renew. Recertification is time-consuming and, at a very busy stage of my life, it wasn’t a top priority.”
Since the rules have changed over the last several years to allow recent graduates to become ABO certified, there is a greater incentive to take the boards right after graduation, but obstacles remain.
“ABO certification has not happened yet due to the demands on my time from building a practice. It would have been much easier to do this right out of residency, and I wish I had had 1 or 2 more cases that would have allowed this.”
“During school, I felt as though I didn’t have the opportunity to start and finish enough of my own cases to ABO level. Once I left, I found myself also unable to start and finish cases on my own as I moved from 1 associate position to another.”
Lengthening the program to 33 months should offer more opportunities for residents to treat enough patients to qualify for the ABO examination. It is clear that if board certification is not achieved soon after residency, there is less likelihood of taking the examination in the future. Although those who have gone through the ABO examination process appreciate the learning experience, there is the perception that board certification has little impact on referrals from dentists or in the selection criteria for patients.
Have you been involved in professional and community activities?
It was gratifying to see that almost all respondents were involved in professional and community activities. In terms of professional activities, they ranged from attending and organizing study clubs, teaching in graduate orthodontic programs, and being involved in the leadership of professional organizations. As you would expect, community activities included organizing and participating in charitable causes, speaking on career day, and coaching an infinite variety of youth sports. In general, the longer they are out of school, the more involved they are in community activities; younger graduates were involved with new practices and young families.
First, a few disclaimers: this was a very qualitative poll of only 1 person per class spanning 20 years. However, in general, the responses were so similar that a larger sample size might not yield significantly different insights. I could have learned more if I had asked more questions. For example, I did not get into issues of the curriculum, such as how much time should be allocated to didactic work vs time spent treating patients vs research. Nevertheless, the responses provide a broad perspective on the UW program and some of the larger philosophic issues of orthodontic education.
The faculty is the heart and soul of the UW orthodontic program. They are teachers, mentors, and role models. Although the full-time faculty administers the program, coordinating the curriculum and research program, the clinical teaching and patient supervision is done in large part by the part-time faculty. A great faculty attracts great students. Many of those students became teachers at the UW and other programs around the country and the world. Since most part-time faculty members are not paid, they must be rewarded in other ways: eg, by activities that emphasize camaraderie and opportunities to participate in research. Similar nurturing and mentorship must be done for full-time faculty. An additional concern locally and nationally is that the salary disparity between full-time private practice and full-time teaching is great, making it difficult to attract the brightest and best orthodontists into full-time academia.
I believe, and the survey responses confirmed, that a collegial atmosphere is a catalyst for learning. At the UW, the faculty sets the tone for the program. Residents feel comfortable challenging the faculty, and the faculty feels comfortable challenging the residents. This environment is best characterized by my experience on the first day of my graduate education. The faculty member in charge of orientation said to the 11 of us: “Call me Bill.” With few exceptions (Drs Moore and Riedel), we were all on a first-name basis, and it set the tone for our education. The faculty has successfully maintained an atmosphere of accessibility throughout the years.
The length of the UW program has evolved over the years from 15 months in the 1950s to its present 33 months. Part of the rationale for lengthening the program has been to allow residents to start and finish more patients; this should be good from an educational point of view and provide more cases to qualify for the ABO examination. Although board certification may not have a great practical benefit at this point, it could in the future. Also, there is every reason to aspire to the clinical standards of board certification. Other reasons for lengthening the program were to provide greater opportunities to complete significant research projects and more time to learn clinical skills. Orthodontics is certainly more complex now than it was 20 years ago. An ongoing challenge for all programs will be the need to balance the value of a longer education with the additional costs to students. This benefit can only be justified if each student’s time is used productively to build needed skills.
Regardless of the length of the orthodontic program, graduates must remain lifelong learners. Educators can’t teach to the future because the future is unknown. A curriculum that emphasizes basic craniofacial biology and biomechanics is critical for providing graduates with the tools to critically evaluate the ever-changing trends in our specialty. I believe that the future is bright for orthodontic education and practice. Advances in biomedicine, dentistry, and technology will ensure that our specialty remains exciting, challenging, and deeply fulfilling.