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.

• 1.

  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.

• 2.

  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.

• 3.

  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.”

• 4.

  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.”

• 5.

  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.

• 6.

  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.

• 7.

  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.