Inside Dentistry
Jul/Aug 2008
Volume 4, Issue 7

An Internship Year for All Dental Graduates

Bruce Donoff, DMD, MD

Former Senator Patrick Moynihan once said to a fellow senator, ?Sir, you are entitled to your own opinions, but you are not entitled to your own facts.?

The American Dental Association House of Delegates voted to eliminate live-patient clinical exams in 2000. Canadian dental graduates take an Objective Struc-tured Clinical Examination (OSCE) exam for licensure. Several states have changed their dental practice acts to permit licensure by mentored experience of a general residency or specialty. Dental students have led the fight to eliminate a practice that perpetuates unprofessional and potentially illegal activity (by Institutional Review Board [IRB] policy) with some results.

All that led me, at interviews in November 2006, to ask our applicants for oral and maxillofacial surgery residency the following question: ?When you return to school next week, your dean will ask you and all your senior classmates to a meeting. He or she will tell you that all of the US dental school deans have decided not to permit live-patient-based exams to be given at their schools in the spring of 2007. What would be your reaction to this?? Most said they would jump for joy; another few asked for clarification of their own position; but a few asked, ?How will we know if we are qualified to be dentists??

Unbelievable, I thought, and asked these applicants whether the faculty had been observing, evaluating, and teaching them, and providing feedback and judgment on their competency for several years. They answered yes, but were a bit perplexed by the thought of such a change. The truth is we all often do not see things the way they are, but the way we are and the way we see things depends on where we stand. That is the student?s dilemma, the practitioner?s dilemma, and the profession?s dilemma. The need for a postgraduate year (PGY)-1 for dental education is not, however, about licensure. It is about producing the best dentists for the 21st century, who can build on the great traditions of the dental profession.

William Gies was not a dentist, but as his knowledge of dentistry?s potential as a health service increased, he realized the necessity of a more comprehensive education to train the future practitioners of dentistry to meet the public?s need. He envisioned dentistry as an agency in public health.

The Gies Report was dentistry?s Flexner Report. Its recommendations influenced the development of the dental profession, and Dr. Gies saw ways to bring about the development of biomedical research for the problems of the dental profession as well as a means to disseminate the findings. This led to the formation of the Journal of Dental Research and the International Association for Dental Research. He brought together several groups to form the American Association for Dental Education and he initiated a section on dentistry for the American Association for the Advancement of Science.

One of the major recommendations of the Gies Report was the call for graduate education in dentistry. Although many look at the report as a call to make dental education 3 years rather than 4, it was the quality, not the time, which was important to Dr. Gies. The importance of the biomedical sciences was paramount, linking with medicine was critical, and the notion of a graduate year not including specialty training was designed to attract a higher caliber of candidates to the field.

Recent press coverage describing the cost of dental care, the lack of access and disparities in oral healthcare, and the use of dental therapists are potential wake-up calls. One can see these as threats or as opportunities. A recent editorial in the Journal of the American Dental Association suggested that workforce changes are paramount to a substantive change in the dental profession and that the dental educational community has the ability to effect overall change.

The current milieu of state dental practice acts, the high costs of dental education, and dentistry?s view of itself as the technical expert of mechanical procedures rather than the healthcare provider of dental medicine constricts the capacity for change. Dental education can change how dentists are prepared, but dental education alone cannot effect the changes necessary. Are dentists collectively up to the challenge?

Henry S. Pritchett, president of the Carnegie Foundation, wrote in the preface to the Gies Report in 1926: ?It should be clearly understood that the proposal to reduce the course for general practitioners in dentistry to three years instead of four is not a step backward. It is an honest and sincere effort, first to secure educated men for the profession and secondly to integrate the professional course for general dentistry into a feasible and effective process of professional training. Under this arrangement a better educated man will devote more hours in three years to direct preparation for his profession than are now given in fours years by men generally less highly educated.?

The Gies Report called for dentistry to gain its rightful place in the service of public health. I have called for a new Gies Report before, but now more than ever the events, conditions, and opportunities for change exist. I see an internship year now, almost like a Peace Corps effort. Do we have the will?

Jim Collins, a well-known business consultant, coined the phrase ?catalytic mechanism? to describe ways to turn goals into results. Such a mechanism produces unpredictable results; it redistributes power away from traditional power holders and toward the overall system, establishes a tangible process that moves the vision towards fulfillment, attracts the right people, and produces ongoing effects. I suggest that a PGY-1 year (whatever its actual form) can be such a mechanism.

I suggest that an internship year or PGY-1 year could be a catalytic mechanism for the improvement of the dental profession, for the improvement and equality of patient care, and for realizing Dr. Gies? dream of dentistry justifying its place as an agency of public health. Echoing Dr. Pritchett?s words, I do not think it would be a step backward. In fact, all of the discussion around change of the predoctoral curriculum might be facilitated if there was an accepted, agreed-upon process for the education and training of the dental professional that included an internship and/or specialty education and training. I might even suggest that all the fundraising efforts being developed for dental education could be redirected and focused toward the goal of creating enough PGY-1/AEGDs for all dental school graduates.

The number of states adopting PGY-1 or AEGD changes in their practice acts is increasing. Dental residents will take care of a greater number of patients with more complicated health problems and from lower socioeconomic groups; they will interact with their medical colleagues more; and they will have direct oversight by practitioners, who are overseers, not just graders. The unexpected result might be real change in dental education and the profession.

Change in the endgame, residency, will lead to change in the game, dental school, and maybe even in the pregame, the college preparatory admissions requirements. The result will be better-educated and better-trained dentists. The result will be a profession that improves the public?s health and well-being.

I am a practicing optimist and truly believe that reasonable people can come together outside of their own organizational silos to reach a solution. John Kenneth Galbraith said: ?Faced with the choice between changing one?s mind and proving there is no need to do so, almost everyone gets busy on the proof.? I suggest that the educators, examiners, state dental board members, and organized national and state dental societies come together for a summit to agree on the problem and come to a solution. Harvard would welcome hosting such a historic meeting.

The opinions expressed in Viewpoint are those of the author and do not necessarily reflect the views or opinions of the editors, the editorial board, or the publisher. To submit an article for Viewpoint, please contact Justin Romano at jromano@aegiscomm.com.

About the Author
Bruce Donoff, DMD, MD
Dean and Walter Guralnick Distinguished Professor of Oral and Maxillofacial Surgery
Harvard School of Dental Medicine
Boston, Massachusetts

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