UOP

A Dental School That Serves the Practicing Profession

Arthur A. Dugoni, DDS, MSD

Copyright 2002 Journal of the California Dental Association.

Author
Arthur A. Dugoni, DDS, MSD, is dean and professor of orthodontics at the School of Dentistry, University of the Pacific.

The School of Dentistry at the University of the Pacific is a bridge between one of the great private universities in the West and one of the nation’s most respected professions. The mission of Pacific is to provide a superior, student-centered learning environment integrating liberal arts and professional education, and preparing individuals for lasting achievement and responsible leadership in their careers and communities. Among its core values are academic distinctiveness, building relationships with our communities, and using outcomes data for continuous improvement. This makes it a unique home for educating competent beginning dental practitioners in a humanistic environment. Pacific may be the only dental school in the United States that is not part of a research-intensive university or a major health sciences campus with their emphases on medicine, basic science research, and cost recovery through tertiary care. Our environment is the world of the private practitioner.

It is the purpose of the School of Dentistry to serve the needs of the dental profession. Our graduates are competent to begin modern private practices and remain current throughout their careers or to enter the best graduate programs. Our professional development program emphasizes hands-on skill-building courses. The research we conduct focuses on clinical applications to the practice of dentistry. We have initiated new programs in oral and maxillofacial surgery and dental hygiene in response to needs identified by the profession. Our clinics provide safety-net services to population groups such as the medically compromised and transient and disadvantaged communities the profession cannot easily reach. And Pacific continues to provide its share of exceptional leaders for the profession.

Competency-Based Education

It is no surprise that competency-based professional education began at Pacific. Competency means the capability to begin independent professional practice and acceptance of responsibility for continuous professional development. This replaces the old model where the curriculum was driven by a desire of the faculty to tell everything they know. There are three problems with that older view. With a big enough faculty and an exploding knowledge base, the curriculum would expand beyond reasonable limits. There is always the danger that what teachers find interesting and important may not efficiently match what practitioners need. And finally, learners should be given the opportunity and ultimately full responsibility for being able to direct their own professional growth.

Competency-based professional education begins by identifying the skills, understanding, and supporting values required to begin practice. The faculty at Pacific has identified 59 such competencies. Among these are "evaluate the range of available dental therapies for individual patients’ dental, medical, and personal situations, including advantages, disadvantages, and risk-benefits rations," "perform simple and surgical tooth and root extractions," "function as a patient’s primary and comprehensive oral health care provider," and "think critically, solve problems, and base dental decisions on evidence and theory." If this sound more like what practitioners do than schoolwork for students, that is as it should be. Competencies, not numerical requirements, drive the graduation decision.

The competency approach to curriculum design is now practiced in all U. S. and Canadian dental schools. It is a requirement of the accreditation process. Competency-based education is also beginning to appear in other professional programs such as nursing, dietetics, law, and business. But Pacific remains the only dental school that drives its educational program based entirely on the needs of practitioners. For example, we are the only dental school that completes the four-year predoctoral program in 36 months. That is possible because we have eliminated the activities that do not directly support initial competence. This has required careful differentiation of what is essential compared with what is nice to know and awareness of how the profession is changing. The faculty has also developed the perspective that the curriculum belongs to the whole faculty and is not a collection of disciplines that fight for clock hours.

Competency-based education views learning as a 10- to 15-year journey through the predictable stages of novice, beginner, competent, proficient, and mastery or expertise. The first three stages are accomplished in dental school. The four-academic-years-in-36-months curriculum at Pacific is accomplished by dramatically shortening the novice stage and somewhat telescoping the beginner stage. Clinical education, where competency is achieved, is actually expanded. Pacific students are among those in the top half dozen in the country in clinical experiences, consistently performing 10 percent to 15 percent more dentistry than the national average, and doing so with one fewer year of overall education. Pacific was a pioneer in the early 1970s of the comprehensive patient care model of clinical education. This is an essential foundation for competency-based education because dentists must learn to integrate a wide repertoire of skills, understanding, and values in realistic settings. Novices are very good at doing what the faculty tells them to do, and beginners are good at getting requirements (doing what they need to do). Only competent practitioners are good at doing what is in the patient’s best interest.

Not all learners achieve competence on the same time schedule. Years ago, to break the traditional lock-step sequencing of the dental school curriculum, we introduced "breathing spaces" at key points where students who needed tutorial assistance could get it. It turns out that this also provided the opportunity for a rich array of selective courses throughout the three years. In some years, a few students are retained at the end of three years for additional clinical experiences. Last year, we added enrichment experiences in the final quarter for nine students who were deemed competent before the nominal graduation date.

The proof of the competency-based approach to dental education is in the performance of our graduates. Table 2 shows the four-year yield of our program since 1993. This is not the pass rate on state boards; it is the proportion of students who first enter the program and are qualified to practice independently four years later. The two or three percent who do not achieve competency include those who have difficulties with state or national boards, are extended for further training by the faculty or who repeat, and those who are dismissed, change their career goals, or experience severe illness or other personal problems. Our three-year yield, the proportion that is qualified to practice in 36 months, has now reached 87 percent.

By focusing on the needs of practicing professionals rather than academic disciplines, Pacific has proven that dental education can be effective and efficient.

Humanism and Leadership

I have frequently stated that we have the privilege of educating outstanding young men and women at Pacific, and along the way they become doctors. A large part of being a professional is who one is, not just how smart or talented one happens to be. It will not do just to train the head and hands and leave out the heart. Although we teach modalities that are state of the art; the care that our graduates provide must be state of the heart.

Humanism and leadership are not optional at Pacific. Among the competency statements developed by the faculty are "establish and maintain patient rapport" and "participate in organized dentistry." We feel the profession expects and deserves this of the young people entering the dental profession.

Humanism is a major part of the culture of the dental school. Over the years, faculty and administrators have learned how to challenge and motivate students to excel, how to correct problems in patient care, and even how to take criticism from students in ways that preserve students’ self-respect and individuality. There has been a self-selection for these traits. The students’ view matters. In regular meetings, students meet with the administration and faculty on a regular basis to discuss how the program can be improved. All student suggestions are taken seriously, investigated, and acted upon if appropriate; and then students are told what happened. Students are active members of all committees, including the faculty appointment, promotion, and tenure committees. Participation, including funding for attendance at national meetings, is encouraged for student representatives to the American Dental Association, the American Student Dental Association, the California Dental Association, the American Dental Education Association, and several research associations. Student government is active and currently includes 12 percent of the entire student body.

Students in all dental schools have been active in community service and outreach. Screenings, foreign missions, and fund-raising activities are typical examples. At Pacific, the emphasis has been on full participation. For the past two years, 100 percent of each graduating class has participated in some form of community outreach. This program -- called SCOPE, for Student Community Outreach for Patient Education -- is run by students as a way of instilling the values of "giving something back to the community." The profession should be proud of this level of involvement.

The values of humanism and leadership learned in dental school continue through one’s professional careers. They affect the way dentists think of themselves and how they interact with their patients and staff. These values also influence involvement in the profession. Two ADA presidents in recent years were Pacific faculty members (Drs. Arthur Dugoni and Burton Press). Seventeen percent of the dentists practicing in California are graduates of Pacific. A count from the Leadership Directory of the California Dental Association reveals that 41 percent of the state and component society officers in this state are Pacific graduates. The contributions of talent, time, and treasure to the profession and the school speak volumes regarding the satisfaction our alumni feel with their careers. Humanism and competency together are a powerful mix and a strong foundation for the future of the profession.

Helping Meet the Needs of Special Patient Populations

Every dentist cannot provide care for every type of patient. But the profession as a whole needs to provide this broad range of services to retain the public’s trust. Each of the dental schools in California helps provide such "safety-net" coverage, and Pacific has its own special niches.

Dental schools have traditionally been clinics where patients traded time for money: They pay a little less because the care takes a little longer. We are not satisfied with that arrangement at Pacific. One of the elements in our overall mission statements is to "provide patient-centered, comprehensive, quality care in an efficient clinical model that demonstrates the highest standards of service achievable." Our clinic mission statement affirms, "The mission of the school’s clinics is to provide patient-centered, quality oral health care in a humanistic educational environment." We are working to move away from the model of compensating patients for the inconvenience we impose and toward reducing that inconvenience to a minimum. The competency-based approach and humanism both require this. We have cut the time required from initial screening to first therapeutic procedure in half and decreased "redos" by 40 percent in the past five years. Recalls are up, and chart audits show a significantly improved quality of care. We truly seek to model appropriate and comprehensive patient care rather than focus on isolated technical procedures.

Because of our location in San Francisco, Pacific has been a long-time and active participant in the Ryan White program. This is a national program that reimburses health care providers for the extra expenses involved in treating HIV-positive and AIDS patients. For the past five years, the clinics at Pacific have provided more than 5,000 professional visits for these patients per year. Our Advance Education in General Dentistry program has a national reputation for its work with patients who have developmental, emotional, and other disabilities. We are currently in the second year of a program funded by the California Endowment to establish regional treatment centers and train dentists and other health care professionals to provide care to patients with special needs in their own communities.

Pacific has a tradition of establishing partnerships with the profession for bringing care to underserved communities. Our Union City Dental Care Center was built to serve a group of patients in the East Bay by gifts from our alumni in 1976 and remodeled in 2002. We are currently building a treatment facility to bring care to underserved patients in San Joaquin County. For the past two years, Pacific has received more scholarships for establishing dental practices in areas with low dentist-to-population ratios than the other California schools combined. We also rotate students through clinics in Northern California that have been created by component dental societies and communities to reach the underserved. In this way, dental students learn first-hand about the sense of responsibility that the profession must demonstrate to serve the underserved and provide access to care.

Another example of helping the profession provide the full range of care to patients is the creation of a hygiene program. In the fall of 2002, we will accept the first class of 32 students in the nation’s first three-year baccalaureate dental hygiene program. This will be a joint program on the campus of our parent university in Stockton. Students will complete 18 months of general education and prerequisites in the biomedical sciences with the university faculty and then finish with 18 months of clinical training in clinics that are currently under construction on the campus. Not only will this help address the critical shortage of hygienists for practice, it will also ease the even more critical shortfall of educators for hygiene programs. This program has had the guidance, endorsement, and financial support of the San Joaquin, Fresno-Madera, Stanislaus, and Sacramento District dental societies.

Competence to Mastery

We have served the profession incompletely if we only graduate competent beginning dentists. Two of the stages in professional development occur following graduation. With practice, and certain kinds of help, dentists become proficient and then they become experts. Pacific has begun to offer help here as well.

We have intensively studied our graduates during the first 12 years of practice. For example, we have discovered that they borrow almost 1 1/2 times as much to start their practices as they did for their dental education. They also pay back their loans in from seven to 10 years, at about 10 percent of their practice income, and their default rate is among the lowest of all professionals -- less than 0.2 percent.

Recent graduates feel competent in a broad range of procedures and gradually reduce the variety of techniques performed (through referral) to customize a practice in which they can become true experts. Beginning practitioners are outstanding learners. They use a blend of formal continuing education, journals, peers, observation of their own outcomes, and other sources to remain current. And they are current. There is no difference in the frequency of using newly developed techniques (such as implants, veneers, cosmetic approaches) between those who were taught these techniques in school and their older colleagues who learned the techniques themselves. (Recall that part of the definition of competency is to assume responsibility for one’s continued professional development.)

One skill our recent graduates identified as being an increasing concern is the blizzard of new product claims. Never before has the profession been subjected to so many and such quickly changing messages about how to practice. In response, we have added in each curriculum year material and even whole courses designed to develop competency in critical thinking. Although we teach the traditional material on research design and statistics, our true focus is on how to read an ad, use the Internet to find out what the patient is learning, and how to think through product claims as independent professionals.

Table 2 shows that Pacific graduates tend overwhelmingly to become independent owners of their own practices. The 96 percent ownership level within a decade of graduation compares favorably with the national average of just more than 80 percent in a dentist’s lifetime. Although Pacific graduates are more likely to start a "scratch" practice or to associate and less apt to work as employees than are graduates of other schools, many also specialize before starting practice. Graduate programs are an excellent way to accelerate the proficiency stage of the learning curve.

In the days of the College of Physicians and Surgeons, we had most graduate programs, but amalgamation with the University of the Pacific required consolidation where we could demonstrate strength. From 1967 to 1990, we offered graduate training only in orthodontics, with a two-year program leading to the master of science in dentistry degree in addition to the certificate. Our Advanced Education in General Dentistry program -- with emphasis on special-needs patients -- has been in place for 12 years. A special feature of this program is its emphasis on distance learning. Next year, we will have three campuses in this program -- San Francisco, Union City, and Stockton -- all connected by videoconferencing for didactic instruction and live consultation. The program is part of a national network that has already been sharing course materials and engaging in seminars with simultaneous participation from residents in states such as New York and Arizona.

Our most recent graduate program is in oral and maxillofacial surgery. The Highland Hospital program in Alameda Country has become part of Pacific. This program has two residents in each of four years and a distinguished tradition of training hands-on oral and maxillofacial surgeons. The innovative, three-year baccalaureate dental hygiene program has already been described.

These four independently accredited programs represent Pacific’s response to the growing needs for advanced training in dentistry. Rather than add years to the undergraduate program and require that all students spend more time getting ready to practice, we believe the profession is better served by laying a strong foundation in the shortest possible time and allowing practitioners to choose the direction and depth of additional formal training they desire.

Becoming an expert in dentistry requires years of experience and constant searching for improvement. Pacific’s approach to professional development is designed to strengthen the profession this way. We recognized about 10 years ago that the lecture update courses with big-name speakers belonged to organized dentistry and that we should fill a niche that no one else was adequately covering. What practitioners told us they needed were hands-on extended clinical experiences -- something like the old study club approach. Currently, Pacific offers multiweek, laboratory and clinical, participation courses in endodontics, anesthesia, periodontics, prosthodontics, implants, surgery, and esthetic dentistry. In some of these disciplines, the participation programs are sequenced in as many as three levels of difficulty to form learning continua.

Blurring the Line

The best practitioners are always learning; the best educators are always practicing. Lines between education and practice have been drawn more distinctly than they need to be or than is helpful to the profession. Of the 319 faculty members currently at Pacific, nine are full-time administrators, nine are biomedical scientists, and 46 are full-time. Most of those who are qualified to do so practice one day a week. We have 114 one-, two- and three-day per week faculty members and 152 adjunct (volunteer) faculty members. Virtually all of these continue to practice, and many are among the best-known and most highly respected in their communities. Among recent graduates, an average of 8 percent teaches for some period during the first 12 years following graduation.

Practitioners are drawn to Pacific to share some of what they have learned with the next generation of their colleagues and to be part of the inquiring environment of a dental school. Scholarship -- disciplines, peer-reviewed generation of new and useful ideas -- is expected of every faculty member. This includes adjunct faculty members who are invited to join ongoing teams. Pacific is even developing the concept of the "scholarship of practice," systematic improvements in the practice of dentistry.

Each dental school in the United States is unique or nearly so. What makes Pacific special is its determination to serve the practicing profession.

Legends

Figure 1. Dr. Phil Oppenheimer, dean of the Thomas J. Long School of Pharmacy; Dr. Donald DeRosa, president of the University of the Pacific; and Dr. Arthur Dugoni, dean of the UOP School of Dentistry, help break ground at UOP’s new $21 million Health Sciences Learning Center and Clinics on the Stockton campus. The facility will house a state-of-the-art clinic for the dental school’s new hygiene program and its expanded Advanced Education in General Dentistry program in the Central Valley.

Figure 2. Sohail Saghezchi, class of 2002, presents his senior research project on gene therapy in human oral cancer cells to faculty at UOP School of Dentistry’s annual Research Day.

Figure 3. CDA Speaker of the House and Pacific Alumnus Dr. Sig Abelson, ’69, with his wife, Teri Abelson, receives a thumbs up from their son, Dr. Michael Abelson, ’89, for receiving the School of Dentistry’s prestigious Medallion of Distinction Award at the 103rd Annual Alumni Association Meeting.

Figure 4. UOP School of Dentistry Dean Dr. Arthur A. Dugoni congratulates Courtney Inada, class of 2004, as she receives her white coat and certificate during the White Coat Ceremony at the Herbst Theatre in San Francisco. The ceremony focuses on the importance of professionalism, ethics, and responsibility to the community as the second-year dental students begin their new roles as health care providers.

Figure 5. Student volunteers from UOP’s Student Community Outreach for Public Education organization provide dental screenings and oral health education to adults and children at the annual Chinatown Community Health Fair in San Francisco.