By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management
It’s expensive to become a dentist. Students typically must finance a minimum of eight years of higher education and forgo eight years of earnings before entering the profession. For those who specialize, the costs incurred and lost income are considerably higher. Future physicians, pharmacists, and advanced practice nurses face similar burdens. Even students considering health professions with a shorter educational trajectory often find the tuition costs and the lost earnings prohibitive.
Such concerns prompted the National Academies of Sciences, Engineering, and Medicine in Washington, D.C., to convene a series of workshops this spring on the affordability of health professions education. I spoke on a panel that looked at the impact of cost on students’ intention to practice primary care or work in rural settings and listened to others over the course of several days. An international roster of educators, clinicians, and economists considered ways to make entry into the health professions more affordable, here and abroad. Among the ideas they raised:
- Shift some costs to employers,
- Train a cost lens on innovation, and
- Restructure health professions education to meet community needs.
Three Ideas Worth Exploring
1. Shift some costs to employers
As health systems scramble to recruit and retain staff, some employers are investing upfront in the education of future hires. Norton Healthcare in Louisville, KY, created a first-of-its-kind program for pre-licensure nurses that is paying off with impressive results. The Student Nurse Apprenticeship Program (SNAP) provides the region’s top nursing students with paid opportunities for on-site clinical learning. Students gain income, skills, and confidence in the nursing role, while the health system gains practice-ready employees. Nine out of ten participants choose to work for Norton after graduation, with 92% staying at the organization for at least one year. The result? Norton saved $47 million in avoided turnover costs in the program’s first decade.
Several other hospital systems have adopted the SNAP model, and several states are promoting and funding similar efforts to help meet their health workforce needs. Dentistry doesn’t have hospitals, but a growing number of dentists work for large group practices and dental support organizations. Might these practices invest in the education of their future employees?
2. Train a cost lens on innovation
Several presenters talked about the potential of innovation to make our enterprise more efficient and increase the return on investment (ROI) of health professions education. They also highlighted the need to justify innovation’s costs. Even when a newer approach is demonstrably better, one workshop participant suggested, we need to ask if the improvement is sufficient to justify passing along the cost to our students.
Innovative loan and repayment programs would almost certainly meet that standard. So might pruning the curriculum; using AI and other tools to allow students to learn independently; sharing faculty and facilities; and continuing education (CE) that extends the learning process after a degree is conferred. One participant mentioned an emergency department that reduced readmissions by 30% among patients at the health system’s skilled nursing facilities by introducing simulation-based CE for its employees. Simulation can be expensive, but in this case it more than paid for itself, and at no cost to those who took part.
3. Restructure health professions education
Here’s a provocative question: Rather than measuring the knowledge, skills, and attitudes of our graduates, what if we measured our success by examining the health of our populations?
This perspective suggests a radical restructuring of our entire educational endeavor, a proposition raised during Day 2 of the workshop. Rather than graduating fully formed health professionals who are prepared for a variety of types of independent practice, one speaker asked, what if we shortened education for some by creating different exit points for generalists and specialists? What if we redefined entry-level practice and continued the educational journey through paid apprenticeships or residencies? What if we started from the needs of the community and developed shorter and narrower programs in response?
It’s been done before. Barefoot doctors with roughly a year of basic medical training deployed to rural villages in China during the Cultural Revolution and significantly improved infection control, morbidity and mortality. If this example sounds a little extreme, consider the University of Global Health Equity in Rwanda, which currently offers a combined bachelor’s degree in medicine and surgery and master’s in global health in just six and half years.
In the United States, we have two successful examples of community-driven education as well. The University of Colorado created the first nurse practitioner (NP) program in 1965 to keep rural Colorado children healthy through vaccination, health education, and other preventive services. In the early 2000s, the Alaska Native Tribal Health Consortium responded to the poor oral health of rural Alaskans by sending a handful of community members to New Zealand for two years of post-high school dental education, which was unavailable then in the United States. These pioneers became the first U.S. dental therapists (DTs). Programs for NPs are now ubiquitous, and programs for DTs have taken root in several states, but degree requirements for both health professions have expanded since their earliest days. There may be lessons here as we consider bold approaches to restructuring health professions programs.
At NYU
Affordability is an especially salient issue here at NYU Dentistry. That’s not surprising, given our location in the nation’s most expensive city. Nonetheless, we are eager to find ways to reduce the economic burden on our students.
One approach we’ve taken is to offer early admission to undergraduates who can meet our requirements in three years of college study through the NYU BA/DDS program. These students arrive well prepared and possess the maturity needed to pursue professional studies. Their experience is in line with that of many of my own dental school classmates, who started their professional studies after just two years of college. Similarly, most of our colleagues from overseas specialize right out of high school. Although their dental education lasts a year or two longer than ours, they enter the dental workforce years in advance of their U.S. peers.
To my mind, encouraging students to seek early admission is a sensible first step all dental schools can take while our community explores potentially disruptive ways to increase the affordability of becoming a dentist. At NYU, we are using our Brooklyn clinic as a pilot site for one such model: High Efficiency Education in Dentistry (HEED). A select group of our D-4s will practice in this location alongside faculty. HEED employs a mentor-protégé model akin to a preceptorship or residency model of clinical teaching.
Education’s Return on Investment
Those of us in dentistry know that dental education continues to provide a strong ROI, and the same is true for our colleagues in dental hygiene. In fact, the job prospects for dental hygienists are excellent right now, with a third of surveyed dentists actively recruiting, and almost 90% reporting that finding hygienists is very or extremely challenging. Dental assistants and lab technicians are also in demand, yet the value of entering the health professions may be far less apparent to young people deciding on future careers. They hear about the cost of education rising but don’t always grasp how their future earnings would offset those costs. Even government statistics don’t paint a full picture. They often measure ROI as debt vs. first-year earnings, a calculation that doesn’t factor in the substantial income growth most dentists experience over time.
Anecdotal accounts in the media can also be discouraging. The example of billionaires who dropped out of college offers a tantalizing alternative to the traditional career path. Meanwhile, the specter of debt and indebted students who never finish their degrees provides a cautionary tale. There’s also this sobering news: The size of the lifetime-earnings advantage that a college degree confers is no longer growing, and unemployment rates for recent college grads are on the rise.
Time for Change
If we want to see a steady flow of new entrants into our professions, we need to do a better job of conveying the ROI message. We also need to make entry into our professions less burdensome. The ideas mentioned above include concrete steps our schools can take today. As for more radical change, recent federal actions that are shaking up the status quo in higher education, health care, and research could provide the impetus for our institutions to seriously consider new approaches to preparing the next generation of health professionals. The way forward may take time to emerge, but I suspect bold actions that reduce costs and increase value — to society as well as individuals — will likely carry the day.
