The cost of private dental education

Dental education is becoming increasingly contested as universities are squeezed for cash and staff, and private providers eye off opportunities to offer clinical training. What does the future hold? By Rob Johnson

When Mohit Tolani was choosing a university to do his dental degree four years ago, unlike students in years gone by, he was spoilt for choice. Tolani had completed his undergraduate degree at the University of Sydney. He could continue his dental education there, or go to one of the newer regional schools, such as CSU or Griffith on Queensland’s Gold Coast, where he had gone to high school. However, is all this choice—both in graduate training and later—indicating a healthy future for dental education, or hiding weaknesses in a system that are going to plague the profession in the future?

“The biggest deciding factor for me was what the university offered its students in terms of clinical exposure,” Tolani says. “I researched Griffith and found out their School of Dentistry had a new clinic opening up. They have this new high-tech, digital equipment in the clinic and there’s a lot of newness in the program.”

Another selling point for Tolani was the pragmatic aspects of the course such as the prosthodontics program looking at building dentures, which he saw as helping with diagnoses in the future.

“Having permanent staff on campus in the dental school, who are specialists, was a big deal,” he adds. “We also have visiting casual dentists who supervise us in clinic—for example, oral maxillofacial surgeons who are normally lecturing and a specialist endodontist.”

While Tolani’s experience has been positive, some students will occasionally express disquiet about the education they are receiving. The publication of an article at the end of April on the need for more geriodontics training at dental schools stimulated an online discussion on the Bite website about the tight supply of qualified teaching staff.

“It’s a real problem, and governments have to look at dental education, training and research across Australia,” says Professor Chris Peck, Dean of the Faculty of Dentistry at the University of Sydney. “We’ve had this organic growth of dental schools. It has not been coordinated. It’s been done in a way to meet the needs of certain regions but importantly, there has been no consideration for academic workforce.” In short, he says, no-one is sure where the teaching and research staff are coming from.

“Some of the schools are looking at two pathways. One is recruiting the best we can from both Australia and internationally. The second is, how can we grow our own staff? For example, the next meeting of the Australasian Council of Dental Schools has got that on their agenda about comparing and contrasting staff development programs, to see if we can actually work out a combined approach.”

One door opens …

While that discussion continues between established universities, the private sector is watching green shoots of opportunity appear with interest. For example, a few weeks ago, Dr Brad Wright and Geoff Parkes, two of the founders of the Australian College of Dental Education (ACDE), met in Sydney to discuss, among other things, how and where they could offer clinical training to dentists.

While ACDE was originally established to fill a gap in business training for dentists, it soon became clear to them that while universities grappled with funding and staffing pressures, the educational sector outside of universities was, in Geoff Parkes’s words, “akin to a dog’s breakfast”.

“We were running CPD [continuing professional development] seminars and assisting clients in the market on a range of things to do with the practice, from evaluations to setting up, to operations and staffing,” he explains. “As a result of the discussion between Brad, myself and Bettina Purcell, our other partner, we concluded we were in a space that was ill-defined. We saw an opportunity to formalise it and put some structure to it.” They set their sights on becoming an accredited higher education training organisation—which opened the door to offering independent clinical training.

Dr Brad Wright adds, “Post-graduate clinical education seems to be: go to a hotel room, get a lecture and go home. People are in clinical programs but there are opportunities to conduct clinical training in a different way.”

Dr Wright, a former Queensland president of the Australian Dental Association, is coming in from a unique position, having come from a post at the University of Queensland and several decades’ work in managing dental practices. He adds that the notion of true clinical training being offered by private providers is still a “long way off”, but that the path the profession is on seems clear.

“Universities are struggling across the board to provide clinical experience and any general practitioner we speak to complains that students are graduating without clinical experience. Albeit everyone knows that their education was better than the younger generation, but even if you take that factor out, there is still evidence of schools where students just aren’t getting a number of patients.”

“The biggest deciding factor for me was what the University offered its students in terms of clinical exposure.” Mohit Tolani, Griffith University student

Fee pressures on those clinics are exacerbated, he says, by patients having the option to get their dental work done elsewhere, cheaper. In the past, university clinics and public clinics were a patient’s only low-cost option. Now, he says, private dentists can become more efficient through help from dental auxiliary staff, which in turn places fee pressure on the university clinics. “That has been a big problem compared to the number of dental schools, the number of patients around, and the locations of those schools,” he adds. “Clinical experience is going to be a huge problem in the future.”

Adding to that is the staff problem. “The number of academics who are prepared to devote themselves to clinical education is diminishing all the time, so you’ve got a number of universities across the country all competing for a limited number of academics,” he says. “That creates problems. Some universities are prepared to employ academics who could not get registration within Australia. But all of that seems to combine to get outcomes that some people don’t think are good enough.”

Professor Chris Peck disputes the notion that the current crop of dental graduates aren’t as well educated as they were previously: “There has always been concern by some groups that the new graduate does not have the range of clinical skills that they should, and if you talk to dental practitioners who have graduated some time before, they’ll often compare themselves with new graduates, which I think is a bit unfair.

“The demographics of the population have changed and we have many more people who have chronic diseases, and people who are on multiple medications. Twenty years ago, we didn’t see the same range of health issues, which require new skills and knowledge to deal with the resulting problems. You really need to focus on having research intertwined with education. Otherwise, we’re not going to be able to meet the community needs.”

However, as the competition increases to serve the career-long educational needs of dentists, there have been suggestions that a tightening of the accreditation process for private providers may spill over to greater scrutiny on the education provided by universities.

“There’s talk that the Australian Dental Council (ADC) would move from accrediting universities solely to considering a national board exam in order to graduate dentists,” says Dr Wright. “I understand that currently it’s in the background, but at some point, universities won’t be the only providers of dental education on the graduate level. That means some universities and some post-graduate or undergraduate education providers may not get across the line at the board exams. Today, my understanding is every university that’s applied for ADC accreditation has received it. Whether that will continue, who knows?”

The money problem

The metaphorical gorilla in the room, however, is money. “The big problem with the clinical components of dental education is they’re really expensive components, and if we had a course where we didn’t need to provide clinical education, we would do very well financially in dental schools,” says Professor Peck.

A number of years ago, the Australasian Council of Dental Schools did a funding review with the Government to investigate the costs for training and educating a dental or oral health therapy student. While no-one debated Australia’s commitment for putting funding into higher education, the results of the review made very clear the financial challenge of dental education.

“The cost varied from $35,000 per student per year up to about $90,000 per year, and the $90,000 was in the clinically intensive, senior years,” explains Professor Peck. “When you see a student who has a Commonwealth supported place, which equates to income of about $30,000, you see there’s a big mismatch between what you can get from government support, and what it costs.

“There is real pressure. Perhaps a solution is to look at a consortia between schools—some way of sharing curriculum resources across schools—so we can ensure we’re meeting the needs of the community with regards to oral health.”

“The number of academics who are prepared to devote themselves to clinical education is diminishing all the time … and that creates problems.” Dr Brad Wright, ACDE co-founder

Professor Peck also doesn’t see this as a problem that can be fixed by private entrants into the market. “The problem with clinical teaching in the professional entry-level courses, like oral health therapy and the general dentist, and having private or industry looking after the clinical education, is unless they’ve got revenue coming in from another source, they’re not going to be able to make ends meet.”

So the post-graduate and CPD space becomes the contested one. “We’ve got some post-graduate specialty programs where we utilise a model where the students who are registered dental practitioners under supervision can do part of their education and training in their private practice,” says Professor Peck. “That’s because the demand from students is flexibility. If they’re a graduate, and they have bought into a dental practice, or are practising already, if there was an option that they don’t have to give up their own practice, for what has been traditionally a three-year full-time graduate specialty program, we think this provides much better education opportunities. So we’ve been trialling exactly that and it’s been working quite successfully. It’s for a special calibre of student—one who is experienced—because while they have supervision, it’s up to them to arrange with their mentor regular sessions. While it’s not the true private model, taking ownership of the clinical education, it’s quite an interesting model and I’m certainly open to having public private partnerships in this.”

There is also furious agreement that rules around CPD need to be tightened up for it to mean anything. “If you look at CPD across the country, not much of it is truly independent and if it’s not independent and it’s not actually assessed or regulated, you’d have to have doubts about its value,” says Dr Brad Wright. “Nonetheless, some of it is excellent. There are people providing good CPD and not exclusively dental associations that may well increase.”

What the future holds

Thanks to advanced technology in dentistry, the dental industry is adapting to the digital age and embracing innovation in ways never seen before.

Furthermore, the professional educational space that Mohit Tolani will graduate into is one that is currently very uncertain. One thing Tolani is certain of, however, is that it will be a contested space, and one that requires even greater engagement of recent graduates. Dentistry was perhaps the last profession where you got your degree and walked out of the university gates into a job.

But Tolani sees the competition as a positive. “A lot of private providers run these courses for young dentists who’ve graduated and are universally wholesaling to others, where they do hands-on, community training. What I take from that, as a student, is the fact that there are many avenues to gain your skills.

“The opportunities are endless. Ultimately, there could be a head-butt moment between private and public providers in terms of dental education. I think in the next five-to-10 years as the job market gets tight and competition skyrockets, everyone’s going to do everything possible to get the maximum benefit from any aspect of industry where they can advance their knowledge and increase their awareness.”