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The main objectives of this study were to identify current prosthodontic resident demographics and to analyze factors that may influence applicants in selecting prosthodontics as a career, as well as a specific prosthodontic program. We also investigated the influence of age, gender, relationship status, and year in program on applicant decisions.
Two questionnaires were mailed to all prosthodontic residents (N = 304) registered with the American College of Prosthodontists (ACP) Central Office. Part I assessed resident demographics and factors influencing choice of specialty. Part II assessed factors influencing the selection of a specific prosthodontic program.
Completed surveys were obtained from 193 of 304 (63.4%) of all prosthodontic residents registered at the ACP Central Office. The completed surveys represented approximately 48% of the total population of prosthodontic residents in the United States. Demographic data revealed that 37% and 62% of the respondents were female and male, respectively (1% did not report gender). The mean age of the respondents was 30.3 years. More residents reported being married than either single or in a relationship. Most residents were accepted to their top choice program. Part I of the survey revealed that the complexity and challenge of treatment planning/treatment, ability to lead multidisciplinary cases, possession of skills/talents suited to the specialty, enjoyment of clinical work, and the intellectual content of the specialty were reported to be the five most influential factors in choosing prosthodontics as a career. Part II demonstrated that applicants place a high emphasis on clinical education, their impression of the program director, advice from predoctoral mentors, their impression of resident satisfaction and happiness, and the opportunity to place dental implants. The factors of least importance are climate and opportunities to moonlight, teach, and conduct research.
Dental students consider the complexity and challenge of treatment planning and execution of prosthodontic treatment to be the most important factors in the decision to specialize in prosthodontics. Mentors and predoctoral instructors also strongly influence students. Applicants consider clinical education to be the most important determinant in program selection, but are also influenced by their impression of the program director and his/her philosophy of training. Faculty board certification and the opportunity to place dental implants are also important factors. Relationship status can significantly affect an applicant’s choice of program. Teaching and research opportunities appear to be of minor importance to applicants. These findings can be used by the ACP and/or program directors to understand which factors are important to students, enabling them to assess the compatibility of their programs with applicants and modify existing curricula to make their programs more attractive to top candidates.
Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of the oral function, comfort, appearance, and health of patients with clinical conditions associated with missing or deficient teeth and/or maxillofacial tissues using biocompatible substitutes.1 This specialty was recognized by the American Dental Association in 1947.2 Prosthodontists constitute 2.0% of all professionally active dentists in the United States.2 During 2004–2005, 400 residents were enrolled in 46 prosthodontic training programs in the United States.3
Over the past 30 years, many studies have attempted to identify trends and new developments in predoctoral prosthodontic education, with no emphasis on postdoctoral prosthodontics. Compared to other dental specialties, studies regarding postdoctoral prosthodontic education are scarce.4,5 In medicine, numerous articles exist describing factors that affect a medical student’s choice of specialty. Some factors include role models, type of patients, lifestyle, amount of indebtedness, and long-term career goals.6–9 Surprisingly, no such published literature exists in the dental field. The goals of this study were to identify current prosthodontic resident demographics, to identify which factors influence students in choosing prosthodontics as a specialty, and to analyze many of the factors applicants consider as they select a specific program after deciding to specialize in prosthodontics. In addition, we hypothesize that gender, age, relationship status, and year in program (different classes) influence these selection factors.
Two surveys based on Sledge et al10 with some modifications were created and approved by the IRB office at Harvard Medical School. Part I consisted of a 17-item questionnaire assessing resident demographics and factors that influence students as they contemplate prosthodontics as a career. Part II consisted of a 36-item questionnaire addressing factors that applicants consider when choosing a specific prosthodontic program. Mailing address information (N = 304) was obtained from the American College of Prosthodontists (ACP) Central Office. The surveys were distributed to prosthodontic residents in the United States on September 25, 2006. A second mailing/reminder was distributed on October 26, 2006. Of the mailed questionnaires, only responses returned within 1 month of the second mailing were accepted for analysis.
The respondents were instructed to grade each of the selection factors based on the following numerical priority scale (a Likert-type scale): 1 = extremely important, 2 = very important, 3 = important, 4 = minimally important, 5 = not important, and 0 = nonapplicable response. They were asked to indicate their gender, age, relationship status (single, married, in relationship), year in the program, current institution, and if the program they entered was their top choice. Space was allotted for additional comments.
The data collected were entered into Microsoft Excel 2003 (Microsoft, Seattle, WA) and analyzed using STATA 9 (College Station, TX). The means and standard deviations for each response were calculated and ranked. Descriptive statistics were calculated to describe the study population. Subgroup analyses were conducted using the Wilcoxon rank-sum test for binary variables and the Kruskal–Wallis test for categorical variables.
Completed surveys were obtained from 193 of 304 (63.4%) of all prosthodontic residents registered at the ACP Central Office. Eight mailings were returned due to incorrect address. Five surveys were received after the deadline and were not used for analysis. The completed surveys represented approximately 48% of the total population of prosthodontic residents in the United States. Of the 193 returned surveys, 20 were military respondents and were excluded from Part II analysis. This is due to the fact that military residents indicated to us that they are assigned to a particular location or have no choice of specific locale. As a result, they are not subject to such analysis. The data in this report reflect the adjustment for this exclusion.
Table 1 gives demographic characteristics of the survey respondents. The distribution of the respondents was 47 (24.3%) first-year residents, 53 (27.4%) second-year residents, and 67 (34.7%) third-year residents, with 26 (13.4%) constituting others/ no data. The majority of the respondents (90.15%) were accepted at their first choice school.
A mean response score and standard deviation were calculated for each of the items in the questionnaire. The responses were then ranked in ascending order of mean size (Table 2). The most influential factors to the respondents when choosing prosthodontics as a specialty were (1) the complexity and challenge of treatment planning/treatment, (2) the ability to lead multidisciplinary cases, (3) possession of skills/talents suited to the specialty, (4) enjoyment of clinical work, (5) intellectual content of the specialty, and (6) the influence of mentors/instructors. Length of residency, career plans before entering dental school, and influence of family members in the dental profession were some of the factors given the least priority in ranking.
As shown in Table 3, the variables have been ranked in order of importance to applicants, in ascending order. As one might predict, the most important factor in the selection of a specific program is the diversity of training experience. Applicants also place a very high emphasis on their overall impression of the program director and the philosophy of training at the institution. The amount of time dedicated to clinical experience and the volume of patients are also of major importance. An applicant’s general impression of the program, perception of resident satisfaction and happiness, and influence of predoctoral instructors and mentors were also highly ranked items on the survey. The opportunity to place dental implants is another factor that proved to be of high importance. Factors such as salary, benefits, funding to attend extramural conferences, cost of living, and amount of required lab work proved to be of moderate importance. The factors of least value to prosthodontic applicants include climate, proximity to family, geographic location, amount of free time, amount of time allotted for vacation, social and recreational activities, and opportunities to moonlight, teach, and perform research.
Perhaps one of the most important decisions an individual makes during life is career choice. Being that approximately one-half of waking hours are spent at work, with many additional hours spent pondering work-related issues, the importance of this decision cannot be underscored enough. Having the opportunity to choose a specialty is a luxury granted to the top students in dentistry and medicine. There are many factors that play into the decision to specialize and, if one elects to do so, which field to pursue.
Once the decision is made to specialize, one must decide where and under whose direction to train. In medicine, surgery, and some dental specialties, applicants must participate in the National Residency Match Program11 or the Postdoctoral Dental Matching Program,12 which allow qualified students to rank programs in order of preference. These programs, in turn, rank the applicants in an ordinal manner and a computer program ultimately selects where the student will be training. This system can potentially select a program or location that is dissatisfactory to the resident. In addition, some programs may have unmatched positions due to ranking incompatibilities, which leaves programs and unmatched applicants “scrambling” to fill the open positions. Students interested in prosthodontics participate in a less formal application process that allows them to potentially be accepted to many programs with the opportunity to choose their destination. Those individuals with the greatest academic and clinical achievements throughout college and dental school often reap the benefits of their successes by selecting their “top choice.”
In 1998,Waldman reported that, based on ADA data in 1995, women represented 8.6% of prosthodontists.13 A 2004–2005 survey of Advanced of Dental Education reported that 33% of prosthodontic residents were women (127/396).3 In our study, the ratio of women in prosthodontic training was 37% of the total responding population. As the proportion of female dentists increases, prosthodontics has attracted more female dentists than ever before. Despite the fact that women bring many positive qualities to the specialty and are equally qualified, studies have shown that female dentists, in general, work fewer days and hours than men, which may contribute to a shortage of prosthodontic services in the future.4,14
The mean age of respondents was 30.3 years, ranging from 24 to 46 years of age. Our results also showed that 66% of the responding first-year residents were greater than 28 years of age, 62% of the second year were greater than 29 years of age, and 64% of the third year were greater than 30 years old. A typical US dentist is approximately 26 to 27 years of age at graduation, compared to the non-US graduates who are between 24 and 26 years old at graduation. This information suggests that the majority of residents do not enter graduate training immediately after graduation. The resident might have been in private practice as a general dentist or have pursued another advanced degree. Higher debt loads or the desire to get more experience may delay matriculation. Almost half of the respondents were married, which could serve as an additional factor to delay entrance into postgraduate training. In this study, we stratified the respondents based upon age, with the first group being ≤30 years old and the remainder being >30 years. As expected, the residents who were ≤30 years old were significantly influenced by the residents from their previous dental school, most likely due to the fact that they were recently in contact with the residents (p = 0.04, Table 4).
The influence of mentors/instructors as role models has been known to have a positive impact on a student’s specialty choice.7–9 It has been demonstrated that the best way to influence future applicants should not be to intentionally recruit students, but to demonstrate enthusiasm and sincere love for the profession.7 Prosthodontics constitutes a major component of dental school education and is the backbone of modern dentistry. Mentoring from the initial stages of training, as well as a positive interaction between prosthodontic faculty and residents with dental students may aid in attracting high-quality applicants to our field. In this study, we observed that female residents were more influenced by prosthodontic residents when deciding to specialize in prosthodontics than their male cohorts (p = 0.03, Table 4).
Good income and level of educational debt, on the other hand, were among the least important selection factors, which was in agreement with previous research;6 however, single and married residents felt that the level of educational debt is significantly more important compared to residents who were in a relationship (p = 0.01, Table 4). Residents who are married may have more financial responsibilities, such as children and a nonworking partner, whereas residents who are in relationships may have the opportunity to share their financial obligations. With increasing debt burden placed upon dental students and recent graduates, the tendency to subordinate financial considerations to educational ones may change in the future. A recently published article shows that lifetime earnings after the completion of postdoctoral prosthodontic training are more than sufficient to cover the costs of advanced education and provide a positive return to the prosthodontist.15 In addition, to address this issue, the ACP created the American College of Prosthodontists Education Foundation (ACPEF) in 1985. Since its inception, the ACPEF has been committed to supporting students who pursue advanced prosthodontic training, as well as sustaining research in prosthodontics and related fields. More scholarships and fellowships derived from endowments or private funds, such as the David H. Wands fellowship at the University of Washington and the Straumann Implant scholarship at the Harvard School of Dental Medicine, should be established in the future.
It is apparent from our results that applicants for advanced prosthodontic training are most interested in obtaining a high-quality clinical education. Training diversity and philosophy, amount of clinic time, high patient volume, and opportunity for experience in dental implant placement are among the most important variables considered by applicants as they choose a program. This response is not surprising, being that clinical prosthodontics has such a broad scope and the main reason for seeking advanced training is to attain as much clinical knowledge and experience as possible in 3 years. Similar results have been reported in medical journals.16–19 Although it was detected as marginally statistically significant (p = 0.04, Table 5), it is interesting to see the different trends between first-year residents and their seniors regarding the importance of placing implants. Because dental implants have become such an integral part of contemporary dentistry, the importance of receiving adequate training is being stressed, even at the predoctoral level.20 Perhaps the next generation of prosthodontists will be more involved in the placement and restoration of implants than their predecessors.21
Applicants also consider their overall impression of the program director and his/her philosophy of training to be extremely important. The program director is largely responsible for determining the scope of clinical, didactic, and research knowledge residents receive during postdoctoral training. As such, these results are not surprising and confirm those of previous studies.17,22 The first-year residents placed a significant emphasis on the number of board-certified faculty members, when compared to their seniors (p = 0.03, Table 5). This could reflect an increase in training expectations from applicants, perhaps due to the high cost of advanced training in recent years. Advice from predoctoral mentors and instructors also plays a strong role in an applicant’s choice of program. This has a much greater influence than that of prosthodontic residents from their dental school, which was ranked much lower. Current resident satisfaction and happiness is another factor that is considered highly important to applicants,18,19 as would be expected.
Relationship status also appears to play a role in program selection (Table 5). Single residents considered the opportunity to teach to be more valuable than did those in relationships (p = 0.02). This may reflect the fact that residents in relationships have less available time to dedicate to lesson planning and teaching. Married individuals considered proximity of the program to their families to be significantly more important than those who were single (p = 0.01). Married applicants also report a significant influence of their spouse in their program choice, when compared to singles or those in a relationship (p = 0.00). Applicants under the age of 30 placed a higher emphasis on availability of social and recreational activities in the vicinity of the program than those over the age of 30 (p = 0.03). Lastly, climate and geographic location were observed to be of little importance to applicants, which is in contrast to other reports.10,19,22,23 Being that prosthodontics residents spend the vast majority of their waking hours within the clinics and laboratories of their respective institutions, this factor was expected to be of minimal importance; however, our medical and surgical colleagues also spend a significant amount of time in the hospital, so it remains unclear why this discrepancy exists between prosthodontists and physicians.
This is the first study investigating factors that may influence dental students in choosing prosthodontics as a career and which residency program attracts them the most. The findings of this study have important implications for dental students and prosthodontic graduate programs. The findings, hopefully, will provide useful data to guide future students in selecting a prosthodontic program. Likewise, the ACP and/or program directors will be able to use this information to attract more suitably matched applicants in the future. This will likely be of benefit to program directors as they strive to make their programs as attractive as possible to top candidates.
This study had a few noteworthy limitations. First, the data reflect the opinion of 64% of residents registered with the ACP Central Office (48% of the resident population). The data may not demonstrate the true prosthodontic resident consensus. Secondly, open-ended and validated questionnaires should be provided in the future. A more active participation from the students is needed in the future to achieve a better, more representative response.
Within the limitation of the study, the data revealed that the complexity and challenge of treatment planning/treatment is considered to be the most important factor by dental students as they choose prosthodontics as a career. The role of mentors/instructors/residents plays a significant role in influencing students to become prosthodontists. Applicants consider clinical education to be the most important determinant in program selection. Applicants are strongly influenced by their impression of the program director and his/her philosophy of training when choosing a program. Residents place a higher emphasis on faculty board certification than in previous years. Applicants place a high value on the opportunity to place implants. The importance of this factor has increased significantly in recent years. Relationship status can have significant effects on an applicant’s choice of program. Teaching and research opportunities appear to be of relatively low importance to applicants.
The authors would like to acknowledge Drs. Bruce G. Valauri, Stephen D. Campbell, Patrick M. Lloyd, and Frank J. Tuminelli for giving suggestions regarding the survey. The authors wish to thank all residents who generously devoted their time and effort to completing our survey.
This study was partially supported by the Greater New York Academy of Prosthodontics student research grant (Dr. Ryan Blissett).