An Update On Practice Management Instruction in U.S. Dental Schoo

University of Nebraska Medical Center
DigitalCommons@UNMC
Journal Articles: College of Dentistry College of Dentistry
Spring 3-2012
An update on practice management instruction in

U.S. Dental Schools
David G. Dunning
University of Nebraska Medical Center, ddunning@unmc.edu
Wenyu Qu
Vanderbilt University
Brian M. Lange
University of Nebraska Medical Center, blange@unmc.edu
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Recommended Citation
Dunning, David G.; Qu, Wenyu; and Lange, Brian M., "An update on practice management instruction in U.S. Dental Schools" (2012).
Journal Articles: College of Dentistry. Paper 11.
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‫م خدا‬‫بن‬
OPEN ACCESS Freely Available Online
Special Communication
An Update on Practice Management

Instruction in U.S. Dental Schools
a
, David G. Dunning a, Wenyu Qu b
Abstract
a College of Dentistry, University of Ne- Over the last twenty-seven years, the evaluation of practice man-
braska Medical Center, Lincoln, NE, agement in dental schools has been documented by three studies.
USA.
In twenty-seven years the teaching of practice management has
been influenced by changes in the definition of practice manage-
b Molecular and Cellular Biology Major, ment, resources available to dental schools, technology, changes in
Vanderbilt University, Nashville, TN, accreditation standards and, more recently, the influence of corpora-
USA. tions marketing to dental students.
In an effort to determine what resources dental schools are utilizing
to teach practice management, fifty-seven schools were contacted,

and fifty faculty members with teaching responsibilities were identi-
Correspondence to:
fied. An on-line email survey was administered and results reported
Brian M. Lange at the 2011 meeting of the American Dental Education Association
College of Dentistry, University of Ne-
Section on Practice Management. At the section meeting breakout
braska Medical Center, 40th and
groups discussed two questions. First, identify innovative tools,
methods and ideas in the area of practice management. Second,
Holdrege Sts., Lincoln, NE 68583-0740,
what changes may be necessary to meet recently updated accredi-
USA.
tation standards 2-17 through 2-19. The recommendations of the
Tel: +1-402-472-1274
breakout groups are presented in detail.
blange@unmc.edu

Received: February 15, 2011
Accepted:March 20, 2012 Key words: Practice management; Dental education; Service learn-
Published: March 24, 2012 ing; Dental curriculum.
Copyright: © 2012 Lange BM, et al. This is an open-access article

distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
doi:10.5436/j.dehy.2012.3.00056
journal
Lange BM, et al. An update on practice management instruction in U.S. dental schools
Introduction the National Boards, dental deans may di-

rect scarce resources to higher profile are-
In 1980 the Section on Practice Admin- as of instruction. Concomitantly, there is a
istration of the American Association of growing acknowledgement of the im-
Dental Schools first published curricular portance of practice management instruc-
guidelines for practice management [1]. In tion. The competencies for the new dentist
1984 the first thorough review of practice approved by the American Dental Educa-
management curricula was published [2]. tion Association in 2008 [7] include seven
This was followed by revised curricular items under the “practice management”
guidelines for practice management [3]. and “informatics” categories. These seven
Manski et al. [4] then conducted a survey comprise 19% of 37 approved competen-
study focusing on the seven major areas cies. Graduating senior dental students
identified in the 1986 curriculum guide- continue to ask for more instruction in this
lines. Manski et al. indicated that little had area.
changed since the original 1984 findings, Corporations have aggressively mar-
suggesting that practice administration keted their practice management services
curricula were well-developed and stable and instructional offerings to schools or to
in an era of decreasing availability in cur- dental students. These corporations have
ricular time. Lange et al. [5] revisited the inculcated their influence in many dental
question of practice management curricu- schools, ranging from lunch and learn ses-
la. They found shifts in both the content of sions to outsourcing of the majority of
the material and the methods of teaching. practice management instruction. The ob-
Nearly twelve years have passed since vious problems of quality, bias, apparent
data collection was conducted regarding endorsement and salesmanship mix to-
the practice management curricula in U.S. gether in a questionable concoction of
dental colleges [5]. Many changes have corporate influence in the dental curricu-
taken place in dental education since that lum. This influence has grown so great
time. Dental colleges continue to struggle that the American Dental Education Asso-
with resource issues and economic chal- ciation Section on Practice Management
lenges, to the point of “crisis” if current fi- presented program on this problem in
nancial trends continue [6]. Since there is standing-room only session in Orlando at
no emphasis on practice management in the 2006 annual session [8]. The influence
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journal
An update on practice management instruction in U.S. dental schools Lange BM, et al.
these variables have had in the past dec- contact information for approximately 50
ade (and continue to have) on practice faculty members from the 57 dental col-
management instruction remains unclear, leges. In January and February of 2011,
particularly in light of the newly ap- email surveys (see questions and results
proved competencies and anecdotal im- below) were administered to all 50 of the-
pressions about increased corporation in- se faculty members. At least two email
volvement in this instruction. Dental col- invitations to participate were sent. As
leges need to understand how well and to necessary, follow-up calls were made to
what extent competencies are being administer the survey over the phone, re-
taught. The purpose of this study was to sulting in 33 useable surveys. This repre-
answer basic research questions about the sented 58% (33 of 57) of the dental colleges
basic instructional parameters of practice in the United States.
management instruction in U.S. dental
colleges--faculty allocation to the subject Results
matter, other allocated monetary re- The following survey in quotation marks
sources, types of instructional methods, was developed to obtain data. Results are
number of courses, number of credit listed next to each corresponding ques-
hours and the role of corporations in prac- tion. In order to clarify, we define practice
tice management instruction. management as the body of knowledge
and skills that prepare dental students to
Methods understand and utilize perspectives from
Between June of 2010 and January of 2011, business management, finance, econom-
the administrator overseeing curriculum ics, marketing, law, technology and be-
in all 57 dental colleges were phoned to havioral science in order to manage a den-
identify the key faculty person charged tal practice.
with teaching/coordinating the practice 1. How many faculty full-time equiva-
management curriculum. New dental lents (FTEs) does your dental school de-
schools lacking a full contingent of stu- vote specifically and exclusively to prac-
dents/faculty were purposely excluded tice management instruction? You may
from the sample. Contact information answer in a fraction such as .3 as needed.
was obtained using the American Dental Mean = .55, Range .1 - 2.5
Education Association's Institutional Di- 2. Are monetary resources available for
rectory [9]. These phone calls resulted in practice management program develop-
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ment (for guest speakers, purchase of Service Learning = 11 (33%),

software, etc.)? Not Sure in Service Learning = 8 (24%)
Yes = 10 (30%) No = 23 (70%) 8. What is your assessment of how your
If Yes, how much funding per year? current achievement in practice manage-
Mean = $13,800, Range $3,000-$50,000 ment in the area of accreditation stand-
3. Please check each of the methods of in- ards?
struction you use to teach practice man-  Do not meet accreditation standards in
agement competencies. practice management = 0 (0%)
 Classroom exams = 23 (70%)  Minimally meet accreditation standards
 Written assignments/cases/papers/ pro- in practice management = 5 (15%)
jects = 29 (88%)  Clearly meet accreditation standards in
 Take-home exams = 3 (9%) practice management = 11 (33%)
 Dental management simulation = 17  Exceed accreditation standards in prac-
(52%) tice management = 17 (52%)
 On-line learning modules = 7 (21%) 9. What percentage of your practice man-
4. Number of courses in practice management instruction is taught by corpora-
agement? Mean = 2.3, Range = 1 - 8 tions/brokers/practice management con-
Number of total course credit hours? sultants? 27%
Mean = 5.5 10. To what extent do dental school facul-
5. Check each of the following through ty or other university faculty directly
which students demonstrate competency oversee/monitor any instruction done by
 Individually = 19 (58%) corporations/brokers/practice manage-
 In small groups = 3 (9%) ment consultants?
 Both individually and in small groups = None = 2 (6%), Some = 2 (6%), Most = 4
15 (45%) (12%), All = 23 (70%)
6. Is your dental school
Private = 17 (52%), Private with Discussion
some state funding = 2 (6%), Public = 14 Identifying faculty who taught practice
(42%) management in U.S. dental schools be-
7. Is practice management also taught in came much more problematic than antici-
Yes in Clinic = 18 (55%), No in Clinic = pated. A few schools were unable to iden-
11 (33%), Not sure in Clinic = 4 (12%) tify faculty, likely indicating that little if
Yes in Service Learning = 14 (42%), No in any practice management was being
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taught. On average, 1.7 emails/phone have dropped from 36% of schools in 1999
calls were made in order to successfully to 15% in 2011, though those still receiving
obtain responses. 3.1 contacts were made resources in 2011 had increased support
on average for those who did not respond. ($13,800 vs. $5,477 in 1999). Many dental
The turnover rate was high at 10% for the schools are under incredible financial
faculty originally identified months earlier stress, and this fact likely explains the
as tasked with teaching practice manage- finding of a lower percentage of programs
ment. We cannot account for the high receiving additional financial support.
level of turnover, other than perhaps the The most popular method of instruc-
general trend of "graying" of dental facul- tion to assess competencies is written as-
ty nation-wide and the related likelihood signments/cases/papers/projects at 80%,
of retirement. followed by exams (70%) and dental man-
Several data points are worthy of men- agement simulation (52%). The use of
tion. The full-time-equivalency average of management simulations appears to be on
.55 faculty was nearly exactly the same as the rise because the reported percentages
the .54 reported in 1999. The reported in 1984 and 1999 were at only 6 and 7% re-
mean contact (instructional) hours of in- spectively. Still, we suspect that the cur-
struction has dropped from 88 in 1984 to rent 52% reported percentage for man-
70 in 1998 to 59 in 2011. Some of the lower agement simulation use also includes
contact hours can be accounted for be- "group practice" type arrangements in
cause ethics instruction was excluded clinics which are mentioned later. Only
from the definition of practice manage- about 8 -10 dental schools currently utilize
ment in 2011 and included in 1999. Ethics the most popular management simulation
instruction was excluded in the 1984 study program, also discussed later.
on practice management. There is some While most faculty members utilize in-
inconsistency in the current study because dividual assessment at 58%, many also
fewer contact hours were reported and yet utilize both individual and group assess-
respondents identified increased course ment to measure competency (45%). The
credit hours of instruction (5.5) in 2011 use of cooperative learning strategies in
compared to an equivalent of 4.7 in 1999. small groups appears to have significantly
increased given that only 13 and 17% of
Monetary resources available to aug- curriculum time was devoted to that in-
ment the practice management program structional strategy in 1984 and 1999.
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Given that 52% of the respondents taught riculum, most instruction is still being
in private dental colleges and that the ma- provided by faculty. When corporations
jority of dental schools are public, the do teach practice management, the trend
sample is biased from private school in- is to have faculty oversight of the instruc-
put. Most respondents reported that prac- tion which should tend to mitigate bias in
tice management is also taught in the clin- the classroom. In point of fact, students
ic (55%), though the rest were either not probably benefit to being exposed to such
sure or indicated "No." This may be a corporate influence since, as practitioners,
missed opportunity to link what is taught they will be bombarded by corporate sales
in the classroom to "wet-handed" clinical people. If the instruction is provided in a
dentistry. Fifty-seven percent indicated learning environment supervised by
that practice management is not taught in knowledgeable faculty, students can learn
service learning or were not sure. This to ask corporate representatives appropri-
again may point to a missed opportunity ate questions and, as the old proverb has
to bridge classroom concepts to clinical it, to separate the wheat from the chaff.
experiences in service learning. There continues to be uncertainty and
Amazingly, 52% of respondents said ambiguity regarding the definition of
that their practice management program "practice management." Some people
exceeds accreditation standards in practice view practice management in its broadest
management. A similar question was not sense, encompassing professionalism, eth-
asked in previous studies. We surmise ics and risk management. Others adopt a
that those who participated in the study more restrictive definition as stated earlier
have developed the strongest programs in in the survey. Even after hearing the
practice management because of the high stricter definition of practice management,
percentage rating their programs as ex- several interviewees still included instruc-
ceeding accreditation standards. About tion in the broader definition (such as pro-
27% of practice management instruction is fessionalism and ethics instruction) when
provided nation-wide by corpora- reporting about practice management cur-
tions/consultants, with most or all of this riculum in their dental schools. No doubt
instruction thankfully being supervised by this resulted in some increase in certain
faculty (82%). This question was not data points such as the number of courses
asked in previous studies. While corpora- and hours of instruction. After reviewing
tions have a marked presence in the cur- the key findings above at the 2011 Practice
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Management Section Program entitled, "Strategic Challenge" version is also avail-

"How Much of a Practice Management able in which students manage practices
Curriculum is Needed?" five small groups in teams, generate a strategic plan, a prac-
discussed two important questions related tice philosophy and make over 20 man-
to practice management instruction. Be- agement decisions over the course of 12 or
low is a summary from the break-out more simulated business quarters. Stu-
groups with some additional commentary. dents track progress by analyzing detail
Question #1: Identify innovative teaching quarterly results, including profit and loss
tools, methods and ideas in the area of statements. Financial analysis ratios can
practice management. also be computed by students using on-
1. Simulate a dental practice expe- line spread sheets to track practice per-
rience in a pediatric/dental auxiliary rota- formance against recommended criteria or
tion, including estimating overhead, ranges. Students complete a strategic plan
production, and collections. These learn- assessment as a capstone learning experi-
ing experiences help students acquire a ence.
foundation for understanding the critical 4. Assign business plan projects to
numbers in dental practice. students in teams to focus on small, rural
2. Utilize the University of Texas communities. Students must complete a
Health Sciences Center at San Antonio number of specific steps including: land
Dental School on-line/classroom combi- purchase, office design and associated
nation curriculum. It focuses on personal costs, loan terms and conditions, operat-
finance in the first two years and practice ing costs and rationales for these steps.
management in the last two years of den- 5. Use cases in a variety of sub-
tal school. For more information, contact ject/skill areas such as human resources,
Dr. Scott Stafford, Practice Dynamics Di- leadership, practice purchase.
vision, Department of General Dentistry 6. Faculty members who teach
[10]. practice management may join the Com-
3. Faculty may consider use of Dr. munity of Interest of the Section on Prac-
David Willis' dental management simula- tice Management. This on-line communi-
tion [11-13]. The simulation options in- ty includes over 50 instructional materials
clude a basic, simpler version in which in- such as cases, handouts and power point
dividual students learn basic concepts in presentations. Interested faculty may con-
practice management. A more advanced tact Dr. Dave Dunning at the University of
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Nebraska (ddunning@unmc.edu) to join 10. Recruit and mentor outside ex-

this growing community. perts as guest speakers/teachers in order
6. While admittedly not innova- to address topical areas for which faculty
tive, using quizzes and exams consisting may not have the necessary
of multiple choices, true-false and fill-in- knowledge/expertise. Examples might
the blank question is a relatively efficient include legal issues in practice taught by
method of measuring individual attorneys with practice management expe-
knowledge and competency. Dental rience and personal finance investing
schools with large class sizes might espe- taught be certified individuals with posi-
cially find this approach helpful. tive reputations in working with dentists.
7. Have students evaluate Question #2, What changes may be neces-
associateship contracts and/or purchase sary to meet recently updated accredita-
agreements from a business standpoint tion standards 2-17 and 2-19 in practice
with the understanding that outside ex- management? These new standards read
perts should be consulted (attorneys, as follows [14]:
lenders, accountants). A sample assign- 2-17 Graduates must be competent in
ment for associateship is available in the applying legal and regulatory concepts
aforementioned Community of Interest. related to the provision and/or support
8. Have students visit dental prac- of oral health care services.
tices /clinics and analyze existing systems 2-18 Graduates must be competent in
and other variables (collection poli- applying the basic principles and phi-
cy/financial policy, appointing schedul- losophies of practice management,
ing, recall systems, staffing, clinical de- models of oral health care delivery, and
sign, leadership, teamwork, etc.). A sam- how to function successfully as the
ple of such an assignment used for extra- leader of the oral health care team.
mural programs is also available in the 2-19 Graduates must be competent in
Community of interest. communicating and collaborating with
9. A dental hygiene program other members of the health care team
which requires students to build systems to facilitate the provision of health care.
such as a perio recall/recare system and to
track clinical efficiency/productivity. Intent
These learning experiences help students Students should understand the roles of
acquire financial literacy. members of the health care team and have
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educational experiences, particularly clini- trate on organizational behavior in addi-

cal experiences that involve working with tion to or rather than entrepreneur-
other healthcare professional students and ship/ownership. For example, more in-
practitioners. Students should have educa- struction in the areas of teamwork, com-
tional experiences in which they coordi- munication networks and supervisor-
nate patient care within the health care employee relationships may become more
system relevant to dentistry." important over time.
1. The new standard, 2-19, may re- 4. There is some ongoing ambigui-
quire some dental colleges to provide ad- ty regarding what disciplines, topics and
ditional learning experienc- skill areas are encompassed by “practice
es/assessments. management.” For example, should ethics
2. At a minimum, dental colleges and professionalism be a part of practice
will have to document and measure expe- management?
riences in the healthcare delivery team, 5. Using resource materials as a
perhaps in a competency framework—for foundation for or to augment classroom
example, tracking the number of success- instruction may lend some legitimacy to
ful medical consultations for patients with practice management courses. Examples
other healthcare providers and perform- include: Dental Practice Transition: A
ing actual or simulated "hygiene checks". Practical Guide to Management edited by
Question #3--Additional Comments Drs. Dunning and Lange [15]; and the
1. There appears to be continued American Dental Association's series of
growth in “corporate dental practice.” books on specific topics (examples in-
Examples include Heartland Dental and clude: Associateships, Valuing a Practice,
Pacific Dental Services. Practice Options and Transitions [16-19].
2. There also appears to be an in- The ADA donated these and other similar
creased interest in graduates to pursue books to every dental college in the U.S.
long-term careers as non- about three years ago. These kinds of re-
owners/associates or as partial-owners of sources may be assigned as readings and
dental practices particularly in light of the exams may be created to test knowledge
growing corporate dental practice model. of the material.
3. In view of points 1 and 2 imme- 6. Teachers of practice manage-
diately above, dental colleges may need to ment share a common and seemingly ev-
add or shift instructional time to concen- erlasting lament—namely, as a group pre-
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doctoral students do not seem very inter- mission to dental school in order to en-
ested in learning about practice manage- hance practice management instruction.
ment while in school, and yet later express Over the past three decades many den-
considerable concern upon and after tal schools have also instituted "group
graduation that not enough instruction practices" in which, typically, general den-
was provided. One reason for this trend is tists coordinate/supervise students in the
that the demands of graduation are so last year or two of dental school in an ef-
heavily skewed towards clinical (tech- fort to teach principles of practice man-
nical) skills that it may be difficult for stu- agement in the clinical context. The Uni-
dents to grasp the importance of practice versity of Missouri-Kansas City advertised
management instruction, let alone devote in May of 2011 [22] for a position of an
the time and effort to necessary to learn "Endowed Chair in Practice Management"
practice management more deeply. to "develop a curriculum that will focus
Students sometimes also receive incon- on exposing students to the realities of
sistent or uninformed advice from infor- running a dental practice, such as how to
mal sources such as relatives, spouses or finance a practice, manage debit, handle
even other faculty, especially about personnel matters, and set realistic finan-
associateships and practice valua- cial goals" and "to manage the day-to-day
tion/purchase. Students may lend more operations of the dental school's proposed
credibility to such sources than appropri- Innovation Clinic, which will operate just
ate, not knowing enough to realize that like a small dental practice." These inno-
this advice may be faulty or incomplete. vative curriculum endeavors tend to re-
This process can thus further exacerbate quire considerable faculty teaching re-
the perceived lack of importance of formal sources, and so consideration needs to be
practice management instruction. given to providing a balanced teaching
Importantly, according the American load for faculty within the context of re-
Dental Education Association's Official quirements for promotion and tenure in
Guide to Dental Schools [20], seven dental specific dental schools.
schools offer joint DDS/DMD and MBA Limitations of this research update on
programs. Further, recent attention has practice management should be acknowl-
been devoted by Dunning et al. [21] to edged. Perhaps most importantly, we
adding business courses and behavioral were able to interview faculty representa-
science courses as pre-requisites for ad- tives from about half of the dental schools,
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in part because several dental schools did pressure from corporations wanting to sell
not at the time questioned (January - Feb- their services to new graduates. In some
ruary of 2011) have faculty assigned to cases corporations offer to provide prac-
teach practice management and/or would tice management curriculum time. If a
not provide this information. Conse- dental school lacks a mission/definition
quently, the findings from the interviews statement for its practice management
may be skewed, most likely in the direc- curriculum, it will find the above pres-
tion of less rather than more practice sures formidable. With a mission state-
management instruction being offered. It ment of practice management schools can
is our estimation and opinion based in develop goals that define how they will
part on the data gathered in this study prepare students to enter the practice of
and on anecdotal discussions with col- dentistry and meet accreditation stand-
leagues from around the nation that ap- ards.
proximately half of the U.S. dental schools As noted above some schools face fi-
currently offer viable courses/curricula in nancial and faculty issues. However, ad-
practice management to include some lev- vances in technology as well as more em-
el of individual/group assessment such as phasis being placed on service learning
exams and/or other methods of evalua- have created two opportunities to expand.
tion. Practice management curriculum, as de-
scribed previously in this paper, can be
Conclusion augmented by on-line practice manage-
As one might expect practice management ment simulations as a vital tool in teach-
curriculum is ever evolving. Practice ing practice management. With the in-
management curriculum is under pres- creased push for more service learning for
sure, pressure from changes imposed by dental students, rotation experiences can
the dental schools' accrediting body, as it be structured to include any number of
should be in order to maintain standards practice management scenarios that stu-
of excellence for students making the tran- dents could analyze while on rotation.
sition from academia to the practice of Students rotating to off-site clinics, wheth-
dentistry. Practice management curricu- er public or private, can review business
lum is also under pressure from dental principles and systems and any number of
schools stretched for resources and faculty practice management topics that will ap-
time. Practice management is also under ply to them upon graduation.
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Service learning may also afford dental Acknowledgments

schools a revenue stream to help replace The authors appreciate the helpful com-
lost clinical income while students are on ments from the reviewer of this manu-
rotation. Indeed, a well planned rotation script. The authors are also indebted to
need decrease clinical revenue and could the faculty who participated in this study
instead serve as source to generate new and to the participants in the small group
sources of revenue. break-out sessions at the 2011 American
Upon graduation, many students report Dental Education Annual Session pro-
they did not get enough practice man- gram on practice management.
agement while in school. A rigorous lay-
ering of practice management learning Authors' contributions
experiences during rotations could help M ai n i dea: by all authors.
soften student criticism about practice Li t erat ure search: by all authors.
management. Students on rotation tend to Dat a i nt erpret ati on: by BL and DD.
want real world dental experience and the M anuscri pt preparat i on: by all authors.
more dentistry the better. However, rigor- Dat a col l ect i on: by all authors.
ous assignments requiring students to Funds Col l ect i on: a subscription to
thoroughly study and analyze business Qualtrics web-based survey--by DD and
principles and systems will help students BL through the use of a professional con-
develop a deeper understanding of prac- sultation fund created by placing students
tice management during service learning in associateship positions in the 1990s.
experiences.
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Hypotheses. tion. Dent Educ 1986;50:236-40.
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journal
and business: opportunities for dental educa-

tion. Dent Educ 2011;75:77-81.
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Citation : Lang BM, Dunning DG, Qu W. An

update on practice management instruc-
tion in U.S. dental schools. Dent Hypothe-
ses 2012; 3: 39-52. doi: 10.5436 /j.dehy.
2012.3.00056.
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Introduction the National Boards, dental deans may di-

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ment (for guest speakers, purchase of Service Learning = 11 (33%),

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Management Section Program entitled, "Strategic Challenge" version is also avail-

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Nebraska (ddunning@unmc.edu) to join 10. Recruit and mentor outside ex-

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educational experiences, particularly clini- trate on organizational behavior in addi-

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Service learning may also afford dental Acknowledgments

50  Vol 3, No 1, 2012 http://www.dentalhypotheses.com

http://www.dentalhypotheses.com Vol 3, No 1, 2012  51

and business: opportunities for dental educa-

Citation : Lang BM, Dunning DG, Qu W. An

This journal utilizes the LOCKSS system to create a

52  Vol 3, No 1, 2012 http://www.dentalhypotheses.com

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