Getting Started
Debt and Practice Profiles of Beginning Dental Practitioners
David W. Chambers, EdM, MBA, PhD; Alan W. Budenz, MS, MBA, DDS; Richard
E. Fredekind, DMD, MA; and Nader A. Nadershahi, MBA, DDS
Copyright 2002 Journal of the California Dental Association.
Authors:
David W. Chambers, EdM, MBA, PhD, is associate dean for academic affairs and scholarship at the University of the Pacific School of Dentistry.
Alan W. Budenz, MS, MBA, DDS, is chair of the Department of Diagnosis and Management at UOP School of Dentistry.
Richard E. Fredekind, DMD, MA, is associate dean for clinical services at UOP School of Dentistry.
Nader A. Nadershahi, MBA, DDS, is a group practice administrator at UOP School of Dentistry.
 |
Escalating student debt for dental education has led some to speculate that beginning practitioners may undertake procedures that are beyond their competence in an effort to augment practice income. This hypothesis was tested directly using a data set containing self-reports of practice profiles across a wide range of procedures and debt for education, practice, and personal purposes. Respondents were 113 individuals who had graduated from a private dental school from 1986 to 1997. Conservative dental practice was measured by comparing frequency of commonly and uncommonly performed procedures in the group as a whole against the profile for each respondent. There was no association between educational debt and propensity to engage in unconventional procedures. Older dentists and those who felt more competent at the time of graduation were less conservative. Amount of practice debt was a better predictor of unconventional practice than was educational debt.
|
This research is not based on emerging scientific principles; it is grounded in rumor. The large educational debt of dental students has led to occasional speculation that this burden influences practice decisions and may even affect the quality of dental care rendered. The current study was undertaken to test the hypothesis that young practitioners tend to exceed their competence and perform procedures that are unnecessary, or at least are unconventional, to service their large debt burdens.
It is certainly true that educational debt is large. In 1998, dentists graduated from American dental schools owing an average $84,000 for their professional education. Educational debt is larger for students who attend dental schools that are not subsidized by state funds -- $108,000 debt for private schools compared to $71,000 for state schools.1-2
Dental educational debt is also increasing.3 In 1988, the average student borrowed $30,000 to complete his or her dental education. This represents an 80 percent increase over a 10-year period to 1998. Correcting for the Consumer Price Index, the growth in real dollars of debt was 60 percent. However, the income of dentists during this period accelerated at a rate almost twice the base inflation rate. The ratio of educational debt to annual net earnings of dentists in 1988 was 0.65. Ten years later, that ratio had risen to 0.69. Interest rates on educational loans declined during this period approximately two-percentage points.4
Although educational debt for dentists has risen and today represents an imposing figure by the standards of many wage earners or of established professionals, it does not seem unreasonable as an investment in a profession that has done well economically.5 While it is impossible to obtain reliable figures, debt involved with establishing a practice must also be considered. The size of practice debt relative to educational borrowing and the change, if any, in the proportion this represents of young dentists’ debt structure also has the potential for influencing practice patterns.
A data set that allows for an empirical test of the association between debt and unconventional practice patterns was created as part of an outcomes assessment survey program regularly conducted at the University of the Pacific School of Dentistry. Graduates from the past 12 years were queried on a large number of items, including debt level and regularity in performing a broad range of dental procedures. The procedures ranged from common tasks such as placing restorations for occlusal protection to less common techniques such as comprehensive mixed dentition orthodontics and guided tissue regeneration. If debt burden pushes young practitioners to practice beyond their competence, it should be possible to detect an association between these variables in the data available. Associations between debt load and willingness to perform unusual procedures was also investigated relative to years since graduation, and practice type (owner, associate, or employee).
Methods
UOP School of Dentistry conducted in 1986, 1992, and 1998 a comprehensive outcomes assessment survey of its graduates from the preceding 12 years of classes.6-8 The aggregate survey collected several thousands of pieces of information ranging from problems with patients and staff to continuing education patterns, the use of evidence in selecting new products, and the proportion of work that was elective or retreatment. Because of its large size, systematically stratified groups of graduates answered overlapping subsets of questions. The overall response rate on the 1988 administration of this outcomes assessments survey was 303 of the mailed 1,638 surveys (18 percent).
The subset of data analyzed here represents 113 respondents balanced for number of years since graduation and whether the practitioner is a practice owner, associate, or an employee. Graduates who were enrolled in advanced education programs or participated in specialty practices were removed from the sample, leaving an effective sample size of 86. Forty-four procedures were rated by the respondents and are listed in Table 1 by order from the most to the least frequently performed. For each procedure, respondents indicated the regularity with which they personally performed such procedures from a choice of four alternatives: "routinely," "sometimes," "rarely" and "never." They were also asked to indicate for each procedure how competent they felt they were at the time of graduation with respect to that technique.
A relative index of "conventional treatment" can be constructed by comparing each dentist’s practice profile to the mean for his or her peers. For each of the 44 procedures, the proportion of respondents saying they routinely performed the technique was calculated. The profile of procedures for individual dentists was then weighted by this "routineness" value for each of the techniques the dentist performed and an average taken for each dentist. A dentist with a high score on this measure self-reported frequently performing more typical procedures than the peer group does. This variable is thus called an index of "conventional" practice. Dentists with low scores more regularly performed procedures that are uncommon in the peer group.
Respondents also reported personal loan information. In particular, they were asked to give the amount of loans taken for educational purposes, the amount still owed on these loans, the estimated year in which payback would be completed, and the estimated proportion of gross practice income devoted to paying back these loans. The same four questions were asked regarding debt incurred to purchase and equip a dental practice and the amount of loans taken for personal reasons such as the purchase of a home or car.
Results
Table 1 lists the 44 procedures studied in this survey. Three values are given for each procedure: frequency, weighted frequency, and weighted competence. The frequency score is the proportion of dentists who report performing the procedure routinely or sometimes. The weighted frequency score is an average across dentists based on frequency, with higher scores given for routinely performed procedures. A score of 2.0 means that dentists report on average performing the procedure "sometimes." The weighted competency score is the averaged self-report of competency in the procedure at time of graduation. A score above 2.0 means the typical student felt he or she was competent or better.
Table 2 displays the self-reported debt load of respondents. The average of all borrowing for education, practice, and personal reasons is $364,000. Even though this sample is composed of graduates from a private dental school, the largest components of debt are for personal reasons (51 percent more than for education) and for starting a practice (44 percent more than for education). The payback period is shortest and the percent of practice income largest for paying back practice loans.
The results of tests for correlations among characteristics of dentists in their first 12 years of practice, their debt burdens, and the conservativeness of their practice profiles are shown in Table 3. Level of educational debt is significantly related to both length of time since graduation and practice type. More recent graduates have higher unpaid educational debt and dentists practicing as employees or as associates also have larger unpaid debt. There is a trend toward dentists who felt they were more competent at graduation to have higher educational debt and for dentists who have been in practice longer to have greater unpaid debt associated with purchasing a practice.
There are no significant correlations between unpaid educational, practice, or personal debt and conventional nature of practice profiles. The associations tend to be in the direction of larger debt being coupled with more conventional practice. Amount of debt for purchase and establishment of a practice is a better predictor of unconventional practice than is educational debt. The same conclusions are drawn if amount borrowed is substituted for amount owed and if the second, more liberal, measure of conventional practice is employed.
Discussion
The hypothesis that recent graduates who have larger debt will have practice profiles that are more unconventional than their colleagues who have less debt or than more senior dentists was not confirmed in this survey of graduates from the past 12 years at the UOP School of Dentistry. If anything, there is a trend for larger debt, especially larger educational debt, to be associated with more conventional practices and for more senior dentists to be less conventional. There is a statistically significant association between more unconventional practice and self-reports of confidence at gradation. It is reasonable that students who felt themselves to be better prepared have developed practices that offer broader ranges of procedures to their patients.
The often-noted connection between debt and year of graduation and practice type was also found in this research. The more years since graduation from dental school the less likely a dentist is to work as an employee and the more likely he or she is to own a practice. It was also found that larger educational debts (both amount borrowed and amount still unpaid) are associated with more recent graduates and with employees and dentists working as associates. Much has been made of both of these associations, some authors arguing that larger debts are forcing recent graduates away from practice ownership.3
It would appear that the data in this research support the hypothesis that larger debt discourages or delays practice ownership. An alternative explanation can be found in the natural connection between practice type and years since graduation. Both of these are associated with debt -- greater educational debt correlating with more recent graduation and with practice type. How much does educational debt contribute to our understanding of practice type once we have accounted for the shared associations with years since graduation? This type of question is customarily addressed with stepwise multiple regression9 where the natural association between years in practice and practice type is forced into the equation first and the additional explanatory value of debt is assessed. When this is done, years since graduation explains a statistically significant 25 percent of the variance in practice type and educational debt adds nothing.
Conclusion
This survey of graduates from the previous 12 years at a private dental school was undertaken to determine whether there is an association between debt load and preferring more unconventional procedures in practice. No evidence could be found linking the amount of money borrowed for educational purposes with a propensity to perform procedures that others regard as unusual. Confidence in the null effect interpretation is increased in this study by the fact that the low reported correlations are both positive and negative (and thus unlikely to be affected by changes in statistical power), and the detection of statistically significant associations between riskiness of practice profile and other predictors.
This research was conducted at a dental school that currently has the fifth-highest annualized tuition in the United States. Even so, educational borrowing was only 75 percent of borrowing to establish a practice and 66 percent of personal borrowing. Over the past decade, default rate on educational loans by graduates of UOP have been one-quarter the national average among dental graduates. Historically, the increases in educational debt have nearly matched the increases in expected earnings from dental practice. There was no detectable association between the amount of educational borrowing or debt and willingness to engage in unusual dental procedures.
References
1. Ferrillo P, Report of the President’s Commission on the Cost of Education. American Association of Dental Schools, Washington, DC, 1998.
2. Myers DR, Zwemer JD, Cost of dental education and student debt. J Dent Educ 62:354-60, 1998.
3. Douglass DW, Cansos LV, Update on student debt: trends and possible consequences. J Am Coll Dent 64:19-23, 1997.
4. Chambers DW, Student debt: the structure behind the numbers. Contact Point 79(1):7-8, 1999.
5. Weeks WB, Wallace AE, Wallace MM, Welch HG, A comparison of the educational costs and incomes of physicians and other professionals. New Eng J Med 330(18):1280-6, 1994.
6. Chambers DW, Problems and problem-solving strategies during the first 12 years of dental practice. J Dent Prac Admin 6:29-34, 1989.
7. Chambers DW, Eng WRL Jr, Practice profile: the first twelve years. J Cal Dent Assoc 22(12):25-32, 1994.
8. Chambers DW, Eng WRL Jr, Tasks and stages of professional growth. J Cal Dent Assoc 22(12):35-42, 1994.
9. Schroeder LD, Sjoquist DL, Stephan PE, Understanding regression analysis. Beverly Hills, CA: Sage, 1986.
To request a printed copy of the article, please contact/David W. Chambers, EdM, MBA, PhD, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115, or at dchambers@uop.edu.
