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The effectiveness of practice management education in orthodontic residencies: the alumni's perspective
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The effectiveness of practice management education in orthodontic residencies: the alumni's perspective
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Content
THE EFFECTIVENESS OF PRACTICE MANAGEMENT EDUCATION IN
ORTHODONTIC RESIDENCIES: THE ALUMNI’S PERSPECTIVE
by
Vivian W. Lee
A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)
May 2010
Copyright 2010 Vivian W. Lee
ii
DEDICATION
To the merciful God, who gives me peace and strength.
To the loving memory of my father, Chi-Yu Wei, who blessed me with countless prayers
and instilled in me the values of perseverance and kindness.
To my mother, Ah-Zau Wei, who loves me unconditionally and sacrificed much for me
to pursue my dreams.
To my husband, Hanson, who is the source of my inspiration and the love of my life.
To my daughter, Karissa, who brings me joy and reminds me of what matters at the end
of the day.
iii
ACKNOWLEDGEMENTS
Dr. Peter Sinclair: Thank you for your tremendous support and guidance on this project.
Thank you also for your mentorship throughout my dental career. You believed in me
and invested the time in making me a better orthodontist. I am privileged to have you as
my role model, and I hope to have the opportunity to share what I have learned from you
with other aspiring orthodontists in the future.
Dr. Robert Keim: Thank you for lending your forte and prompt assistance with the most
tedious but also the most important part of this project—statistical analysis. Thank you
also for serving on my thesis committee, providing invaluable resources from the Journal
of Clinical Orthodontics, and signing the cover letters 502 times.
Ms. Ellen Grady: Thank you for your insight and assistance in designing the survey and
moving this project forward. Thank you also for sharing your expertise on practice
management.
Drs. Joseph Caruso, Kang Ting, Gerald Nelson, Robert Boyd, and Glenn Sameshima:
Thank you for agreeing to participate in the study and providing me with the alumni
contact information. This project would not have been possible without your kind
cooperation.
Drs. Michael Paine and Holly Moon: Thank you for serving on my thesis committee, as
well as providing guidance and support.
Drs. Dan Banh, Greggory Gechoff, Serena Hsu, Warren Schacter, and Paul Upatham:
Thank you for participating in the pilot study and your constructive feedback on the
preliminary survey.
iv
Alumni of LLU, UCLA, UCSF, UOP, and USC Graduate Orthodontics: Thank you for
taking the time out of your busy schedule to complete the survey. This project would not
have been possible without your generous help.
Staff of the Journal of Clinical Orthodontics: Thank you for collecting and forwarding
the completed surveys. Your assistance is greatly appreciated.
Dr. Michael Schneir: Thank you for improving my scientific writing skills and making
this project less daunting.
Drs. Lisa Kai and Jenny Yoo: Thank you for taking care of my patients and helping me
stay on track during my maternity leave. Your friendship and camaraderie are much
appreciated.
v
TABLE OF CONTENTS
Dedication ii
Acknowledgements iii
List of Tables vii
List of Figures viii
Abstract ix
Chapter I: Introduction 1
Chapter II: Hypothesis 5
Chapter III: Literature Review 6
I. Challenging Economic Environment 6
II. Challenging Practice Environment 7
III. Importance of Practice Management and Building Skills 8
IV. Evaluation of Graduate Orthodontic Education 10
Chapter IV: Materials and Methods 17
I. Questionnaire 17
II. Mailing List 18
III. Handling 18
IV. Analysis 20
Chapter V: Results 22
I. Descriptive Statistical Analyses (Page 1 of the Questionnaire) 22
II. Inferential Statistical Analyses (Page 1 of the Questionnaire) 27
III. Descriptive and Inferential Statistical Analyses (Pages 2 and 3 of
the Questionnaire) 28
Chapter VI: Discussion 41
I. Additional Major Findings 46
II. Limitations 49
III. Future Directions 50
Chapter VII: Conclusion 51
References 53
vi
Appendices:
Appendix A: Questionnaire 55
Appendix B: First Mailing Cover Letter 58
Appendix C: Second Mailing Cover Letter 59
Appendix D: Information Sheet 60
vii
LIST OF TABLES
Table 1: Response rate 22
Table 2: Mode(s) of Practice Sorted by School 23
Table 3: Modes of Practice Sorted by Cohort Group 23
Table 4: Practice’s Average Gross Annual Income 24
Table 5: Practice’s Overhead as a Percentage of the Gross Annual Income 25
Table 6: Days Worked Per Month 25
Table 7: Average Number of Patients Seen Per Treatment Day 26
Table 8: Number of Weeks Taken Off Per Year 26
Table 9: Contentment with Current Work Schedule/Income/Lifestyle 27
Table 10: Initial Competency Level by School 29
Table 11: Initial Competency Level on Different Categories 31
Table 12: Amount of Additional Practice Management Education Desired
During Residency by School 33
Table 13: Amount of Additional Education Desired During Residency on
Different Categories 34
Table 14: Current Competency Level by School 35
Table 15: Current Competency Level on Different Categories 36
Table 16: Difference between Initial and Current Competency Levels by
School 37
Table 17: Difference between Initial and Current Competency Levels on
Different Categories 38
Table 18: Value of Additional Resources Used Since Graduation by School 39
Table 19: Value of Different Resources Used Since Graduation 39
Table 20: 2008 Total Stipend or Tuition/Fees of Orthodontic Residency
Programs in California 48
viii
LIST OF FIGURES
Figure 1: Didactic Curriculum Seminar Topics 15
Figure 2: Initial Competency Level on Practice Location & Demographic
Analysis 29
Figure 3: Initial Competency Level on Office Design, Equipment & Supplies 30
Figure 4: Initial Competency Level on Scheduling Principle, Design & Monitoring 30
Figure 5: Initial Competency Level on Practice Promotion and Marketing 30
Figure 6: Initial Competency Level on Patient Insurance Plans 30
Figure 7: Initial Competency Level on Financial Indicators, Budgeting & Analysis 31
Figure 8: Additional Education Desired During Residency on Scheduling
Principle, Design & Monitoring 33
Figure 9: Additional Education Desired During Residency on Patient Statistical
Monitoring 34
Figure 10: Overall Difference between Initial and Current Competency Levels by
School 37
Figure 11: Professional Meetings 40
Figure 12: Specific CE Courses 40
Figure 13: Literature 40
Figure 14: Study Clubs 40
Figure 15: Consultants, Accountants, Lawyers 40
Figure 16: Visiting Other Offices 40
Figure 17: Personal Experience over Time 40
ix
ABSTRACT
Most orthodontic residencies place emphasis on the clinical and scientific aspects
of orthodontics. The purpose of this study is to assess the effectiveness of practice
management training during residency from the alumni’s perspective, comparing four
programs in California to USC where a year-long, 88-hour structured Practice
Management Program has been implemented since 1994.
A 3-page survey was mailed to 251 orthodontists who graduated from LLU,
UCLA, UCSF, UOP, and USC between 1995 and 2005. It consisted of questions
regarding their practice demographics and finances, perceived initial and current
competency levels in practice management, and educational experiences. Data from the
returned surveys (n=110; response rate of 44%) was compiled and analyzed.
All the respondents combined averaged low to medium on initial competency
level in practice management upon graduation, would like to have received moderately to
significantly more additional practice management training during residency, and
indicated medium to high current competency level. The USC alumni rated their initial
competency level in practice management higher (16 out of 18 categories, 6 statistically
significant) and desired less additional training during residency (17 out of 18 categories,
2 statistically significant) when compared to the alumni from the other four schools.
However, there was no significant difference on the perceived current competency levels.
Personal experience over time, continuing education courses, and professional meetings
were the most valuable resources in improving most respondents’ practice management
skills.
x
There is a widespread deficiency in practice management training during
orthodontic residencies, especially in the areas of financial preparation and staff
management. The USC Practice Management Program was perceived to be effective in
better preparing the residents for practice upon graduation and may be used as a template
by other residency programs to implement such changes.
1
CHAPTER I: INTRODUCTION
According to the American Dental Association 2008 Survey of New Dentists,
dental graduates had on average $8,630 in educational debt entering dental school but
$135,460 upon graduation (ADA, 2009). The ADA 2008-9 Survey of Advanced Dental
Education reported that orthodontics and dentofacial orthopedics has the highest average
resident first-year tuition ($29,343) among the twelve types of residency programs
(ADA, 2010). However, it remained the most desirable (approximately 10,000
applications each year since 2004) and the second most competitive (approximately 350
residents accepted each year since 2004) specialty to gain admission.
There are many reasons that fuel aspiring orthodontists’ passion in pursuing this
profession despite the additional financial burden and time investment: the intellectual
challenge, the satisfaction from seeing physical and emotional transformation in their
patients, and the opportunity to develop a life-long relationship with them and impact
their lives. In addition, there are other less spoken ―benefits‖ that make this profession
appealing: flexibility in work schedule, relative lack of emergencies, less physical
demand due to utilization of dental auxiliaries, and higher income potential. Indeed, a
survey study done on 168 residents who attended the Graduate Orthodontic Residents'
Conference at the University of Michigan, Ann Arbor in 1992 showed that future job
satisfaction, lifestyle, and financial security were the top 3 reasons why they chose
orthodontics as a career (Keith, 1994).
According to a recent study on the orthodontic residents’ perspective on their
graduate education, the majority (81.5%) plan to enter private practice after graduation,
2
expecting a median annual income of $400,000-$600,000 (Bruner, 2005). However,
excellent clinical skills alone do not ensure a successful career, especially when a
challenging economic and practice environment does not favor elective treatments. As
graduating residents get ready to embark on the next phase of their professional journey,
many important decisions need to be made. Usually the first ones are practice location,
mode of practice, and method of practice acquisition. With pressure from accruing
interest and repayment of educational loans, new graduates may not be able to become a
sole owner of a practice during the first few years. However, practice management is a
set of skills that is relevant to all aspects of patient care and is essential in equipping
young orthodontists in building a successful career and enjoying the practice of
orthodontics. Once they become practice owners, they will manage practices that gross
an average of 0.5-1.5 million dollars annually (JCO 2009 survey). Without practice
management skills, orthodontists often have excessive overhead and continue to make
mistakes that compromise their ability to deliver high-quality treatment.
Practice management requires background and training that most orthodontists do
not have. The Accreditation Standards for Advanced Specialty Education Programs in
Orthodontics and Dentofacial Orthopedics state that ―the orthodontic graduate must have
familiarity with practice management‖ under the ―supporting curriculum‖ (Commission
on Dental Accreditation, ADA, 2008). According to a study on orthodontic education,
82% of residents are receiving education on practice management (Keim, 2002).
However, the quality and extent of the education are unknown. Most orthodontic training
programs in the United States focus on 3 principal areas: (1) the biological and
3
biomechanical basis of orthodontics, (2) the principles and techniques of clinical
orthodontics, and (3) scientific principles and critical thinking. These are important in
educating competent orthodontists, but an essential fourth element is often missing:
practice management (Sinclair, 2001).
A recent study on dental residents’ perceptions of practice management training
during various specialty residencies showed that ten out of thirteen topics surveyed were
perceived to be significantly more important than the level at which they were being
trained: total quality management, benchmarking to improve clinical practice, utilization
review, measuring patient satisfaction, getting patients the services they need from other
health care practitioners, examining the cost-effectiveness of care delivery, time
management, quality of care affecting a practice’s financial status, dealing with health
care payers, and quality improvement techniques (Houlberg, 2008).
Since 1994, the Graduate Orthodontic program at the University of Southern
California has incorporated a year-long 88-hour structured course on practice
management (Sinclair, 2001). The course covered areas from practice leadership and
goal setting, practice location and development, office management and communication,
office and personal finances, and office staff. There are multiple studies and articles on
the orthodontic education from the residents’ and program directors’ views (Keim, 2002;
Masella, 2002; Bruner, 2005; and Noble, 2009). However, the element of practice
management was briefly mentioned at best, and studies on the perceptions of practicing
orthodontists have never been done. The objective of this investigation was to assess the
effectiveness of practice management training in orthodontic residencies from the
4
alumni’s perspective, comparing USC to four other programs in California (Loma Linda
University, University of California at Los Angeles, University of California at San
Francisco, and University of Pacific). From this study, we aim to determine whether
practice management education should command increased curriculum time in
orthodontic residencies.
5
CHAPTER II: HYPOTHESIS
I. Research Hypothesis, H
a
:
When compared to alumni from other orthodontic residencies, alumni from a
residency with a structured practice management curriculum:
1) Would rate their initial competency level in practice management
significantly higher,
2) Would retrospectively desire significantly less additional practice
management training during residency,
3) Would rate their current competency level in practice management
significantly higher.
II. Null Hypothesis, H
0
:
When compared to alumni from other orthodontic residencies, alumni from a
residency with a structured practice management curriculum:
1) Would not rate their initial competency level in practice management
significantly higher,
2) Would not retrospectively desire significantly less additional practice
management training during residency,
3) Would not rate their current competency level in practice management
significantly higher.
6
CHAPTER III: LITERATURE REVIEW
Challenging Economic Environment
Journal of Clinical Orthodontics (JCO) Biennial Practice Study
The Biennial Practice Study performed by JCO is the primary published source of
financial information for solo orthodontic practitioners. Substantial growth was seen
over the 2005 and 2007 period. However, the 2009 Study reported a relatively flat
orthodontic economy with median gross income rising by only 4%, while operating
expenses increased by more than 12% (Keim, 2009). Consequently, there was a 5% drop
in median net income—the first decline since these studies began—and a 1% rise in the
median overhead rate. In addition, there were several other record-breaking statistics:
1) The reported increase in child case fees was the lowest ever at 6%.
2) For the first time, the median initial payment dropped from 25% to 20%.
3) The median percentage of income attributable to third parties dropped back to its
1981 level, 20%, but the percentage of practices accepting assignment of
benefits reached an all-time high of more than 80%.
Worse yet, the financial data reported in the 2009 Study refer to calendar years
2006- 2008, therefore the full depth of the recession may not yet be reflected.
Survey on the Effect of Current Economic Recession
In another JCO report, 79% of respondents who had 15-30 years of experience
indicated that their practices were affected to some degree (Sheridan, 2009). They
responded to their practice decline by increasing promotion of dental referrals, cancelling
7
or delaying plans to purchase or upgrade major equipment, reducing staff/staff hours,
increasing external advertisement, and charging additional services separately.
There was a cause for concern even among those who had not yet experienced a
decline. They relied on aggressive internal-marketing strategies, a substantial waiting list
of patients on observation, and external marketing or referral promotion. This
demonstrates the importance of practice management skills to maintain profitability
during tough economic times.
Challenging Practice Environment
Increasing Competition
According to the JCO 2009 Practice Study, the median percentage of referrals
attributed to general dentists dropped further from its previous low in the 2007 Study,
while respondents relied more heavily on patient referrals than ever before (Keim 2009).
With the economic downturn and increasing popularity of Invisalign
1
, more general
dentists are practicing orthodontics in order to optimize their revenue, thus referring less
to orthodontists.
Increasing Tuition and Educational Loans
The cost of graduate orthodontic education has been increasing to as much as
$180,000 for tuition alone in a 3-year program and approaching $250,000 with other fees
and expenses included (ADA, 2010). Today’s orthodontic graduates bear a substantial
1
Invisalign, ―the clear alternative to braces‖, consists of a series of custom-made clear aligners that patients
switch out approximately every two weeks to gradually move teeth. Invisalign is designed, manufactured,
and marketed by Santa Clara-based company Align Technology, Inc. Align Technology was founded in
March 1997 and received FDA clearance to market Invisalign in 1998. Today, the Invisalign product
family includes Invisalign, Invisalign Teen, Invisalign Assist, Invisalign Express, and Vivera Retainers.
According to their Fiscal Year 2009 Report, 3995 cases were shipped to orthodontists but 11035 to general
dentists in North America during the fourth quarter (Align Technology, 2010).
8
financial burden and are often forced to work as employees, sometimes at multiple
locations, rather than incurring more debt to enter private practice. In addition, the
continual bombardment of government regulations has eroded the sole practitioner’s
profit margin so drastically that many young orthodontists choose to work for a company
or unite into group practices. These arrangements invite more pressure for production
and potential risks for compromising patients’ welfare (Currier, 2004 and Turpin, 2007).
Importance of Practice Management and Building Skills
According to the JCO 2009 Practice Study, many orthodontists apparently paid
more attention to practice management due to economic pressures limiting case starts and
fee increases—fourteen management methods were used by more respondents, but only
six were used less frequently (Keim, 2009).
Orthodontists appeared to focus on practice building methods associated with
patient relationships during the economic downturn, especially fee-payment
arrangements. Multiple methods were used by more respondents than ever before, such
as participating in community activities, entertainment of and gifts to patients and
parents, seeking referrals from staff members, offering no-charge initial visit and
diagnostic records, no initial payment, and flexible payment arrangements.
Total Quality Management (TQM) in Orthodontic Practice
In healthcare services, quality is defined through three integrated elements:
clinical quality, perceived quality, and cost of quality. Serving quality is serving
excellence. Without practice management skills, quality of care is compromised. TQM
is a scientific business process designed around practice capability and the customer
9
demands and wants (Atta, 1999). It focuses on all aspects of the practice to enhance
patients’ experience, including initial consultation, front office service, billing and
collection, emergency care, appointment scheduling, procedure explanations, and
developing rapport with patients. It is the assurance that every patient, regardless of the
type of malocclusion, is treated to the predictable outcome in short time with less cost,
and that the results attained meet professional standards and exceed patient expectation.
TQM is a competitive advantage and an investment in the practice with assured returns
presented as profit and growth.
Characteristics of Financially Successful Orthodontists
Several survey studies focused on high income orthodontists concluded that they
(Hsu, 1996; Coats, 2000; and Smith, 2009):
1) Emphasize the quality of treatment results and respect in the community, not
personal/practice income,
2) Utilize staff training and delegation, a written office policy manual, and
computerized scheduling,
3) Utilize a treatment coordinator and a management consultant,
4) Take more practice management courses per year,
5) Have main offices encompassing over 3000 square feet with 7 or more chairs,
6) On average see 81 patients per day, work for more than 40 hours per week, and
start 38 comprehensive case per month,
7) Emphasize high quality treatment combined with goal setting in the practice and
remain contemporary (Hsu, 1996),
10
8) Allow their practices to grow if it will increase the net income,
9) View control of overhead as a key principle,
10) Emphasize the competence of staff in determining the success of practice,
11) Believe in marketing (Coats, 2000),
12) Work with practice management consultants, and
13) Establish long-term savings goals (Smith, 2009).
It is clear that in addition to clinic competency, practice management skills are
crucial in achieving financial success.
Evaluation of Graduate Orthodontic Education
From the Program Directors’ Perspectives
There are multiple survey studies and commentaries on the subject of graduate
orthodontic education. The most well known is the series of four Orthodontic Graduate
Education Surveys dating back to 1983 (Sinclair, 1984; Sinclair, 1991; and Rudolph,
1997). The most recent published article compiled data from 1983-2000 to identify
trends and evaluate new developments in orthodontic education (Keim, 2002). It
reported findings from a 346-item questionnaire completed by graduate program directors
in the United States and Canada. The eight major areas analyzed were program
organization, graduate students, faculty, facilities, clinical details, treatment techniques,
research, and curriculum. Among the findings, tuition had tripled since 1983 and
increased by 50% during the 1994-1999 period. Curricular time devoted to clinical
activities had increased, but curricular time devoted to research had declined. With
regard to practice management and general computer usage, 74% of the programs used
11
computers for patient scheduling, 85% for business functions, and 49% for patient
education. Eighty-two percent of the programs by 1999 had practice management listed
as one of the curriculum subjects (compared to 63% in 1983); however no further detail
was available regarding the content or extent of such course.
From the Residents’ Perspectives
Several other studies on orthodontic education were done from the residents’
perspectives. The first was probably the survey done on 168 residents attending GORP
in 1992 (Keith, 1994). For the majority of residents who were satisfied with their
programs, problems and difficulties related to orthodontic training fell into two major
categories: financial stress and family pressures. In addition to the costs of the
application and interview process, tuition and living expenses during the program, those
who went into orthodontics directly from dental school were likely to had already
incurred significant debt, whereas those who returned to school might need to
compromise on existing financial commitments. All the orthodontic residents paid
tuition at some level, and almost half did not receive any stipend at all. Residency
training is time intensive and can create conflicts with family life, especially for those
who needed to work part time to support their spouses and children. Upon graduation,
84% planned to enter private practice, but most (41%) planned to associate instead of
establishing a solo practice or buying in as a partner immediately. Eventually, 44%
planned to own a practice as a 10-year goal.
A follow-up study was done in 2003 on 330 residents attending the GORP at
Harvard University (Bruner 2005). Over half of the residents had received financial aid
12
during their orthodontic residencies, and about one third took out bank loans. The
median overall educational debt was reported to be $101,000 to $150,000, with the cost
of orthodontic training accounting for a third of it. Upon graduation, 81.5% planned to
enter private practice expecting a median annual income of $400,000-$600,000. Sixty-
three percent reported feeling that their educational debt restricted them from going into
full-time academics, further exacerbating the shortage of orthodontic educators in the
future. Residents received stipends of various amounts. However, stipends awarded for
orthodontic education might become a thing of the past because stipends for nonhospital-
based dental residencies have been eliminated from Graduate Medical Education funding.
Describing their 10-year goals, most residents planned to work 4 days a week, with
median annual income goals for women ($200,000 to $400,000) being significantly less
than for men ($400,000 to $600,000).
One article written by a dental student from the University of California, Los
Angeles specifically evaluated the dental residents’ perceptions of practice and patient
management training during postgraduate education (Houlberg, 2008). Residents in
twelve postdoctoral training programs at UCLA were surveyed about the importance of
thirteen topics regarding dental practice and patient management. Residents were also
asked to rate the level of training they received in these areas during their residency and
dental school education. Ten out of the 44 respondents were orthodontic residents.
Results showed that time management, multidisciplinary coordination, and total quality
management were the most important topics. When compared with the results from an
identical survey administered in 1997, time management and total quality management
13
were significantly less emphasized. In addition, dealing with health care payers was
rated as an important topic to their future practices but the least emphasized in their
programs. Therefore, practice and patient management skills were considered important
and desirable to residents and thus should receive appropriate attention from postgraduate
programs to prepare residents for running successful practices.
Practice Management Training during Orthodontic Residency
The importance of practice management training during orthodontic residency has
also been recognized in multiple articles. According to the ―Educational Update‖ in the
January 1996 issue of AJODO, the Council on Orthodontic Education surveyed two
groups—58 chairpersons of postdoctoral orthodontic programs and 100 private
practitioners—to identify elements of an excellent orthodontic program. The element
most frequently mentioned by the 50 chairpersons who responded was a dedicated,
skilled, reputable, and knowledgeable faculty. On the other hand, practice management
was listed by the 33 private practitioners who responded as the third out of the twelve
elements of an excellent program.
Recently, the importance of practice management training during orthodontic
residency has gained recognition by the leaders of orthodontic education globally:
As a strategy in creating superb clinicians, orthodontic teaching and learning must
be based on the demands of orthodontic practice and should mimic the practice
environment to the greatest extent. For example, the technology essential to state-
of-the-art treatment and practice management needs introduction in postdoctoral
education. Full-time educators with substantial practice experience and practicing
orthodontists/part-time teachers provide helpful links between academic and
practice realms and valuable experiences for students (Masella, 2002).
To prepare orthodontic graduates to face the real world, the graduate orthodontic
curriculum should also emphasize the development of communication skills
14
practice management, ethics medical law, health-care financing and appropriate
patient-doctor relationships (Kharbanda, 2006).
The most thorough article regarding the incorporation of practice management
curriculum into orthodontic residency is ―Preparing to practice and manage: A program
for educating orthodontic residents in practice management‖ (Sinclair, 2001). According
to the article, commitments from the faculty, the staff, and the residents are required to
develop a successful curriculum. The first commitment involves running the graduate
clinic like a contemporary orthodontic practice. The second commitment is providing the
time needed in the curriculum (2 hours per week for at least one year) to train the
residents. The third commitment involves the assignment of a course director and the
recruitment of lecturers with specific areas of expertise.
The University of Southern California Practice Management Program (USCPMP)
has been operating since 1994 with 4 major components:
1) Structured seminars: 21 hours of instruction are given during the preclinical
phase of the first year to expose the residents to the basic principles and
communication skills necessary to conduct diagnostic procedures and explain
treatment plans. During the second year, weekly 2-hour classes (totaling 88 hours
in 44 classes) on specific topics with assigned reading and discussion are held
(Figure 1). The residents are acquainted with various practice management
viewpoints and systems. During the third year, monthly 2-hour sessions are
provided by the part-time faculty and consultant Ms. Grady to provide more in-
depth information on subjects of interest to graduating residents.
15
Figure 1: Didactic Curriculum Seminar Topics
2) Graduate clinic operations: With the objective of simulating private practice as
much as possible
3) Exposure to well-managed contemporary orthodontic practices
4) The practice management study club: providing a forum in which recognized
experts on subjects of current interest are invited to speak
The objective of USCPMP is to provide the residents with the concepts, tools and
skills necessary to balance professional and personal life goals by avoiding mistakes and
gaining more confidence in the residents’ early years. This research project was done as
a follow-up of this article evaluating the perceived effectiveness of the USCPMP in
comparison to other residency programs. The topics outlined in Figure 1 were combined
16
into 18 categories of practice management on the questionnaire, allowing us to focus on
the subjects that were well addressed by the USCPMP as well as the ones that still need
emphasis.
17
CHAPTER IV: MATERIALS AND METHODS
Questionnaire
A 3-page questionnaire (Appendix A) was developed with input from Dr. Peter
Sinclair (a former Chairman of USC Graduate Orthodontics and a private practitioner)
and Ms. Ellen Grady (an orthodontic practice consultant who also assists in the
management and daily operation of the USC orthodontic clinic as a part-time faculty
member). The questionnaire consisted of fixed-choice questions and tables to be
completed with checks under the scaled answers. The first page contained 11 questions
on the respondent’s background and stage of practice. The other two pages contained
tables that ask the respondent to rate his/her 1) initial preparedness to enter practice upon
graduation, 2) how much more education on practice management he/she would like to
have received during residency, and 3) current competency level on 18 categories of
practice management. The last table asked the respondent to rate the value of resources
used since graduation. There were 72 answers total on a completed questionnaire. A
pilot study was done by mailing the questionnaire to five USC alumni who are current
faculty members of the USC Undergraduate/Graduate Orthodontic Departments (Drs.
Dan Bahn, Greggory Gechoff, Serena Hsu, Warren Schacter, and Paul Upatham).
Questions were modified according to their feedback.
The questionnaire was accompanied by three items: a cover letter (Appendix B),
an information sheet (Appendix C), and a return envelope that was stamped and self-
addressed. The cover letter encouraged survey participation, detailed the survey’s intent,
and guaranteed participant’s anonymity. The information sheet detailed general
18
information on the survey, including the purpose of the project, potential conflicts of
interests, and risks of survey participation. A proposal of the research study and all three
documents mentioned above were approved by the USC Institutional Review Board
(IRB).
Mailing List
With consent from Department Chairs/Clinic Directors of all five orthodontic
programs (Dr. Joseph Caruso from LLU, Dr. Kang Ting from UCLA, Dr. Gerald Nelson
from UCSF, Dr. Robert Boyd from UOP, and Dr. Glenn Sameshima from USC) to
participate in this study, contact information of alumni who graduated between 1995 and
2005 was obtained from each department. The addresses were compared with the
American Association of Orthodontics directory and discrepancies noted. Office
websites and phone numbers were utilized to locate the current addresses. Alumni who
are practicing outside of the United States and the UCLA alumni who were dually trained
under the joint pedo-ortho program were excluded. With collaboration from the Journal
of Clinical Orthodontics, the survey was mailed on Oct 15, 2009 to 251 alumni from
LLU (n=55), UCLA (n=34), UCSF (n=49), UOP (n=56), and USC (n=52).
Handling
The cover letter, information sheet, and survey were printed in the USC
Department of Graduate Orthodontics. To increase the response rate, the following steps
were taken:
1) Letterheads and envelopes were obtained from the JCO with the JCO logo on
the cover letter, outgoing and return envelopes.
19
2) Each cover letter contained the logos from all five schools and was signed by
the USC senior resident, Dr. Vivian Lee, and JCO Editor-in-Chief, Dr. Robert
Keim.
3) The cover letter and survey were printed in color on textured papers with
watermarks.
4) The addresses of the alumni were hand-written and stamps placed on each
envelope.
5) Return envelopes were addressed to the JCO office in Colorado, and
responses were forwarded back to USC for data compilation and statistical
analysis.
6) A label with ―IMPORTANT SURVEY ENCLOSED. PLEASE REPLY BY
(DATE).‖ printed in red was placed on each outgoing envelope underneath the
JCO logo.
7) Second mailing was done on November 25, 2009 to all 251 alumni with their
school logos printed on labels placed on the outgoing envelopes underneath
the JCO logo. A different cover letter was enclosed (Appendix D).
One hundred and thirteen completed surveys were received, and five envelopes
were returned to the JCO office as undeliverable. Therefore, the response rate was
45.9%, which was considered high among survey studies (5.2% for the 2009 JCO
Orthodontic Practice Study and 8.7% for Dr. Gregory Smith’s M.S. thesis on the Factors
in the Financial Success of Orthodontists done in 2009). Three responses were excluded
from the study (one respondent is a full-time faculty, one is in the Air Force, and the
20
other had 18 years of private practice experience prior to entering orthodontic residency).
The information from the remaining 110 surveys was compiled for analysis, yielding an
effective response rate of 44.7%.
Analysis
Each answer was assigned a value (the red number next to or in the answer box
shown on Appendix E) and entered into Statistical Package for the Social Sciences
(SPSS) (Chicago, IL, Version 16) for statistical analysis. ―99‖ was entered for any
unanswered question. For the mode(s) of practice, the following system was used:
1 for Associate
2 for Sole owner
3 for Sole owner with hired associate(s)
4 for Owner member of a partnership (solely orthodontists)
5 for Owner member of a group practice (other dental professionals)
6 for the combination of 1 and 2
7 for the combination of 1 and 4
8 for the combination of 1 and 5
9 for the combination of 1, 2, and 3
For the last question on the first page of the questionnaire regarding whether the
respondent is content with his/her work schedule, income level, or lifestyle, ―0‖ was
entered if the box was unchecked and ―1‖ if checked. The entered information was
reviewed to verify accuracy. For each response, descriptive statistics (frequency, mean,
and mode) were calculated for 1) all the schools taken together as a group, 2) each
school, and 3) each cohort group (all respondents who graduated from 1995-1997, 1998-
2000, 2001-2003, or 2004-2005). Means were compared to identify trends in the
responses.
21
Further analysis was performed to determine whether there was a significant
difference between the schools including one-way ANOVA with Levene’s test of
homogeneity of variances, a priori contrast tests, Dunnett T3 post hoc test, a K-samples
non-parametric Kruskal-Wallis test, a crosstabs procedure with a Pearson chi-square test,
and paired T-test. The findings of the analyses are discussed in the results section.
Voluntary comments written by several respondents were compiled and reviewed
separately.
22
CHAPTER V: RESULTS
Descriptive Statistical Analyses (Page 1 of the Questionnaire)
Each questionnaire item was analyzed to view the distribution of responses.
Response Rate (Table 1)
The completed questionnaires were sorted to tabulate the response rate from each
school and cohort group. The response rate is the highest (63.5%) from the USC and the
lowest (30.6%) from the UCSF alumni. Overall, the response rate (44.7%) is considered
high for survey studies, indicating a strong interest in the topic of practice management
education among practicing orthodontists.
Table 1: Response Rate
School/Cohort 1995-1997 1998-2000 2001-2003 2004-2005 Missing Total Response %
LLU (n=55) 7 3 9 2 1 22 40
UCLA (n=34) 6 3 3 4 0 16 47
UCSF (n=49) 3 6 2 2 2 15 30.6
UOP (n=56) 4 8 2 7 1 22 39.3
USC (n=52) 9 8 9 7 0 33 63.5
Missing 0 1 1 0 0 2 -
Total (n=246) 29 29 26 22 4 110 44.7
Mode(s) of Practice (Tables 2 and 3)
Among all the respondents combined, sole ownership is the most common and
ownership of a multi-specialty group practice the least common mode. The pattern is the
simplest among the UCSF and the most diverse among the USC alumni, which could be
due to the difference in the number of responses from those schools. For the responses
indicating multiple modes of practice, fractions were added to the corresponding modes
and the adjusted total numbers shown in parenthesis in Table 2. For example, if both
―Associate‖ and ―Sole Owner‖ were checked on a completed questionnaire, then 0.5 was
23
added to the ―Associate (A)‖ and another 0.5 added to the ―Sole Owner (S)‖ rows under
the school of graduation column.
Table 2: Mode(s) of Practice Sorted by School
Mode(s)/School LLU UCLA UCSF UOP USC Missing Total
Associate (A) 0 (1.5) 1 (1.5) 3 1 (1.5) 2 (4.8) 0 7 (12.3)
Sole Owner (S) 17 (18.5) 8 (8.5) 11 12 17 (17.8) 1 66 (67.3)
Owner with Hired Associate (O) 1 0 1 2 3 (3.3) 0 7 (7.3)
Partnership Owner (P) 1 6 0 5 4 (5.5) 1 17 (18.5)
Group Practice Owner(G) 0 0 0 1 (1.5) 1 (1.5) 0 2 (3)
A+S 3 1 0 0 1 0 5
A+P 0 0 0 0 3 0 3
A+G 0 0 0 1 1 0 2
A+S+O 0 0 0 0 1 0 1
Total 22 16 15 22 33 2 110
Sole ownership is the most common mode among all the cohort groups as well.
With increasing number of years in practice: 1) percentage of sole owners increases as
expected, 2) percentages of associates and partnership owners decrease. The same
system used above was applied to the responses indicating multiple modes of practice in
Table 3.
Table 3: Modes of Practice Sorted by Cohort Group
Mode(s)/Cohort Group 1995-7 1998-2000 2001-3 2004-5 Missing Total
Associate (A) 1 (1.8) 2 (3) 1 (3) 2 (3.5) 1 7 (11.3)
Sole Owner (S) 22 (22.8) 18 (19) 14 (14.5) 9 (9.5) 3 66 (68.8)
Owner with Hired Associate (O) 2 (2.3) 3 1 1 0 7 (7.3)
Partnership Owner(P) 1 4 5 (6) 7 (7.5) 0 17 (18.5)
Group Practice Owner(G) 1 0 1 (1.5) 0 (0.5) 0 2 (3)
A+S 1 2 1 1 0 5
A+P 0 0 2 1 0 3
A+G 0 0 1 1 0 2
A+S+O 1 0 0 0 0 1
Total 29 29 26 22 4 110
24
Practice’s Average Gross Annual Income for the Past Two Years (2007-2008) (Table 4)
For all the respondents combined, 0.5-1 million (dollars) was the most commonly
reported gross annual income, followed closely by 1-1.5 million. The most commonly
reported gross annual income for UCSF, UOP, and USC alumni was 0.5-1 million and
higher for LLU (1-1.5 million) and UCLA alumni (>1.5 million). On the other hand, the
median gross annual income for all the respondents combined as well as for UCSF, UOP,
and USC alumni was 1-1.5 million. It was higher for UCLA alumni (dual medians of 1-
1.5 million and >1.5 million) and lower for LLU alumni (0.5-1 million). However, the
differences were statistically insignificant.
Table 4: Practice’s Average Gross Annual Income
Gross Income/School LLU UCLA UCSF UOP USC Combined
< $250,000 (1) 1 2 0 1 0 4
$250-500,000 (2) 4 0 0 1 1 6
0.5-1 Million (3) 7 4 5 8 15 39
1-1.5 Million (4) 9 2 4 7 11 33
>1.5 Million (5) 1 7 4 4 6 22
Missing 0 1 2 1 0 4
Mode (4) (5) (3) (3) (3) (3)
Median (3) (4), (5) (4) (4) (4) (4)
Practice’s Overhead as a Percentage of the Gross Annual Income for the Past Two Years
(2007-2008) (Table 5)
For all the respondents combined, the most commonly reported percentage
overhead was 50-60%, followed by >60%. The most commonly reported percentage
overhead for UCSF, UOP, and USC alumni was 50-60% and higher for UCLA (dual
modes of 50-60% and >60%) and LLU (>60%). However, the differences were
statistically insignificant.
25
Table 5: Practice’s Overhead as a Percentage of the Gross Annual Income
Percentage Overhead/School LLU UCLA UCSF UOP USC Combined
<40% (1) 0 1 1 0 1 3
40-50% (2) 4 4 3 2 5 18
50-60% (3) 8 5 7 10 20 50
>60% (4) 10 5 3 7 6 31
Missing 0 1 1 3 1 6
Mode (4) (3), (4) (3) (3) (3) (3)
Median (3) (3) (3) (3) (3) (3)
Days Worked Per Month (including Patient Care and Practice Management/Marketing)
(Table 6)
For all the respondents combined, the most commonly reported number of days
worked per month is 11-15 days, followed closely by 16-20 days. UCSF and UOP
alumni seem to work fewer days per month (mode and median of 11-15 days) than
alumni from the other three schools. However, the differences are statistically
insignificant.
Table 6: Days Worked Per Month
Days Worked Per Month/School LLU UCLA UCSF UOP USC Combined
<10 Days (1) 0 0 0 1 0 1
11-15 Days (2) 10 6 9 13 14 52
16-20 Days (3) 11 8 6 7 14 46
>20 Days (4) 1 1 0 1 5 8
Missing 0 1 0 0 0 1
Mode (3) (3) (2) (2) (2), (3) (2)
Median (3) (3) (2) (2) (3) (3)
Average Number of Patients Seen Per Treatment Day (Table 7)
For all the respondents combined, the most reported average number of patients
seen per treatment day is 41-60, followed by 61-80. UOP alumni seem to see more
patients per treatment day (mode and median of 61-80) than alumni from the other four
schools. However, this difference is statistically insignificant.
26
Table 7: Average Number of Patients Seen Per Treatment Day
Average # of Patients/School LLU UCLA UCSF UOP USC Combined
<40 (1) 5 2 3 4 8 22
41-60 (2) 8 6 8 5 14 41
61-80 (3) 5 5 4 9 7 30
81-100 (4) 4 2 0 3 2 11
>100 (5) 0 0 0 1 2 3
Missing 0 1 0 0 0 1
Mode (2) (2) (2) (3) (2) (2)
Median (2) (2) (2) (3) (2) (2)
Number of Weeks Taken Off Per Year for Vacation and Continuing Education (Table 8)
For all the respondents combined, the most commonly reported number of weeks
taken off per year is 3-4 weeks, followed by almost an equal split between 5-6 and <2
weeks. Among the schools, there are multiple modes and medians of responses. Further
statistical analysis showed that there are significant differences between USC and UOP
alumni as well as between USC and alumni from the other 4 schools combined (please
see ―Inferential Statistical Analyses‖ section below for details); USC alumni take
significantly fewer weeks off per year than do alumni from the other schools, more
specifically UOP.
Table 8: Number of Weeks Taken Off Per Year
Number of Weeks Off/School LLU UCLA UCSF UOP USC Combined
<2 Weeks (1) 4 3 5 2 7 21
3-4 Weeks (2) 8 5 5 5 21 44
5-6 Weeks (3) 2 7 2 8 5 24
>6 Weeks (4) 8 0 3 7 0 18
Missing 0 1 0 0 0 1
Mean (2.64) (2.27) (2.2) (2.91) (1.94**) (2.34)
Mode (2), (4) (3) (1), (2) (3) (2) (2)
Median (2) (2), (3) (2) (3) (2) (2)
* p<.05, ** p<.01, *** p<.001
27
Contentment with Current Work Schedule/Income Level/Lifestyle (Table 9)
For all the respondents combined, 77.3% are content with their work schedule and
lifestyle but only 51.8% with their income level. For each school, the percentages of
alumni who are content with their work schedule, income level, and lifestyle were
calculated. Those three figures were then averaged and listed under the ―overall‖ row.
While the differences are not statistically significant, greater percentages of alumni from
UCLA and UCSF (>80%) are more content with these aspects of their career overall than
the alumni from the other three schools (60%-70%).
Table 9: Contentment with Current Work Schedule/Income/Lifestyle
Contentment/School
LLU
(n=22)
UCLA
(n=16)
UCSF
(n=15)
UOP
(n=22)
USC
(n=33)
Combined
(n=108)
Work Schedule
72.7%
(16)
87.5%
(14)
80%
(12)
77.3%
(17)
75.8%
(25)
77.3%
(85)
Income Level
36.4%
(8)
68.8%
(11)
80%
(12)
40.9%
(9)
48.5%
(16)
51.8%
(57)
Lifestyle
81.8%
(18)
100%
(16)
80%
(12)
77.3%
(17)
63.6%
(21)
77.3%
(85)
Overall 63.6% 85.4% 80% 65.2% 62.6% 68.8%
Inferential Statistical Analyses (Page 1 of the Questionnaire)
For the questions on page 1 of the questionnaire, ANOVA was first performed.
Statistical significance was noted for responses to questions ―weeks taken off per year‖
(p=.003) and ―contentment with income level‖ (p=.04). A priori contrast tests were
performed, which showed that USC alumni differed significantly from alumni from the
other four schools combined as a group on ―weeks taken off per year‖ (p=.001) but not
on ―contentment with income level‖.
Dunnett T3 post hoc test was also performed, which showed that USC alumni
differed significantly from UOP alumni on ―weeks taken off per year‖ (p=.002). Again,
28
no statistical significance was noted under ―contentment with income level‖. Although
the groups varied overall, the differences were too small for pair-wise significance.
Descriptive and Inferential Statistical Analyses (Pages 2 and 3 of the Questionnaire)
Initial Competency Level upon Graduation (Tables 10-11, Figures 2-7)
For this section (Table 1 Parts A and B on the questionnaire), each answer was
assigned a value: Very Low=1, Low=2, Medium=3, High=4, and Very High=5.
Means for the responses from all the alumni of each school were calculated under
the 18 categories of practice management. Overall, the average was the highest among
USC alumni (16 out of 18 categories) and lowest among LLU alumni. Pearson’s Chi-
Square test was performed to identify statistical significance. USC alumni rated their
initial competency level on practice management upon graduation significantly higher in
6 categories. Frequencies of responses from each school are shown in Figures 2-7.
29
Table 10: Initial Competency Level by School
Category/School LLU UCLA UCSF UOP USC
Practice location & demographic analysis 2.24 2.56 2.6 2.05 3.27*
Practice evaluation & buy-sell procedures 2.24 2.19 2.67 2.32 2.9
Associateship principles & procedures 2.14 2.25 3.07 2.32 2.9
Business plans & loan applications 2.29 1.75 2.14 1.82 2.5
Office design, equipment & supplies 2.14 1.88 2.53 2.18 3.21*
Scheduling principle, design & monitoring 2 1.94 2.8 2.05 3.33***
Communication & new patient exam/conference 2.76 2.94 3.4 3.14 3.57
Practice promotion & marketing 1.9 2.38 2.4 2.36 3.03*
Risk management 2.71 3.25 2.8 2.86 3.1
Goal-setting & leadership skills 2.48 2.63 2.73 2.55 3.13
Staff hiring, training, evaluation & firing 1.62 1.56 1.93 1.82 2.3
Staff compensation, bonuses & benefits 1.52 1.5 1.73 1.86 2.1
Patient statistical monitoring 2.24 1.94 2.07 1.82 2.63
Patient insurance plans 1.33 1.5 1.53 1.41 1.87*
Financial indicators, budgeting & analysis 1.57 2.06 2 1.64 2.53*
Contracts & accounts receivable control 1.62 1.81 1.87 1.45 2.3
Business & personal insurance 1.9 2.44 2.53 1.91 2.93
Personal financial goals, investments & estate/retirement planning 1.86 2.56 2.53 2.23 2.77
Overall 2.03 2.17 2.41 2.1 2.8
* p<.05, ** p<.01, *** p<.001
Figure 2: Initial Competency Level on Practice Location & Demographic Analysis
USC UOP UCSF UCLA Loma Linda
University
School
12
10
8
6
4
2
0
Count
5
4
3
2
1
location1
Bar Chart
1=Very Low
2=Low
3=Medium
4=High
5=Very High
30
Figure 3: Initial Competency Level on Office Design, Equipment & Supplies
USC UOP UCSF UCLA Loma Linda
University
School
12.5
10.0
7.5
5.0
2.5
0.0
Count
5
4
3
2
1
design1
Bar Chart
Figure 4: Initial Competency Level on Scheduling Principle, Design & Monitoring
USC UOP UCSF UCLA Loma Linda
University
School
12
10
8
6
4
2
0
Count
5
4
3
2
1
scheduling1
Bar Chart
Figure 5: Initial Competency Level on Practice Promotion and Marketing
USC UOP UCSF UCLA Loma Linda
University
School
12
10
8
6
4
2
0
Count
5
4
3
2
1
marketing1
Bar Chart
Figure 6: Initial Competency Level on Patient Insurance Plans
USC UOP UCSF UCLA Loma Linda
University
School
20
15
10
5
0
Count
3
2
1
ptinsplan1
Bar Chart
1=Very Low
2=Low
3=Medium
4=High
5=Very High
1=Very Low
2=Low
3=Medium
4=High
5=Very High
1=Very Low
2=Low
3=Medium
4=High
5=Very High
1=Very Low
2=Low
3=Medium
4=High
5=Very High
31
Figure 7: Initial Competency Level on Financial Indicators, Budgeting & Analysis
USC UOP UCSF UCLA Loma Linda
University
School
12
10
8
6
4
2
0
Count
5
4
3
2
1
finance1
Bar Chart
For all the respondents combined, the initial competency level on practice
management upon graduation was rated low to medium (mode= low), with patient
insurance plans being the lowest and communication & new patient exam/conference
being the highest.
Table 11: Initial Competency Level on Different Categories
Category All Respondents Combined
Patient insurance plans 1.53
Staff compensation, bonuses & benefits 1.74
Contracts & accounts receivable control 1.81
Staff hiring, training, evaluation & firing 1.85
Financial indicators, budgeting & analysis 1.96
Business plans & loan applications 2.10
Patient statistical monitoring 2.14
Business & personal insurance 2.34
Office design, equipment & supplies 2.39
Personal financial goals, investments & estate/retirement planning 2.39
Practice promotion & marketing 2.41
Scheduling principle, design & monitoring 2.42
Practice evaluation & buy-sell procedures 2.46
Practice location & demographic analysis 2.54
Associateship principles & procedures 2.54
Goal-setting & leadership skills 2.70
Risk management 2.94
Communication & new patient exam/conference 3.16
Overall 2.30
1=Very Low
2=Low
3=Medium
4=High
5=Very High
32
Amount of Additional Practice Management Education Desired During Residency
(Tables 12-13, Figures 8-9)
For this section (Table II Parts A and B on the questionnaire), each answer was
assigned a value: No More=1, A Little More=2, Moderately More=3, Significantly
More=4, and A Great Deal More=5.
Means for the responses from all the alumni of each school were calculated under
the 18 categories of practice management. Overall, USC alumni desire the least
additional practice management education during residency (17 out of 18 categories,
mode=2) and LLU alumni the most. Pearson’s Chi-Square test was performed to identify
statistical significance. USC alumni desire significantly less additional practice
management education in two categories. Frequencies of responses from each school are
shown in Figures 8 and 9.
33
Table 12: Amount of Additional Practice Management Education Desired During Residency by
School
Category/School LLU UCLA UCSF UOP USC
Practice location & demographic analysis 3.24 3.19 2.8 3.5 2.43
Practice evaluation & buy-sell procedures 3.1 3.5 2.8 3.45 3.03
Associateship principles & procedures 3.33 3 2.73 3.41 2.73
Business plans & loan applications 3.29 3.4 3.2 3.36 2.87
Office design, equipment & supplies 3.29 3.25 3.13 3.14 2.33
Scheduling principle, design & monitoring 3.67 3.88 3.33 3.59 2.47**
Communication & new patient exam/conference 3.6 3.06 3 2.73 2.63
Practice promotion & marketing 3.76 3.56 3.2 3.14 3.1
Risk management 3 2.69 2.87 2.82 2.53
Goal-setting & leadership skills 3.14 3.19 2.8 3.32 2.76
Staff hiring, training, evaluation & firing 3.86 4 3.67 3.64 3.33
Staff compensation, bonuses & benefits 3.68 4.06 3.67 3.32 3.21
Patient statistical monitoring 3.59 3.69 3.67 3.32 2.79*
Patient insurance plans 3.73 3.88 3.4 3.36 3.24
Financial indicators, budgeting & analysis 4 3.69 3.67 3.45 3.3
Contracts & accounts receivable control 4.09 3.81 3.53 3.41 3.27
Business & personal insurance 3.59 3.5 3.2 3.09 2.58
Personal financial goals, investments & estate/retirement planning 3.32 2.75 3.13 3.05 2.76
Overall 3.52 3.45 3.21 3.28 2.85
* p<.05, ** p<.01, *** p<.001
Figure 8: Additional Education Desired During Residency on Scheduling Principle, Design &
Monitoring
USC UOP UCSF UCLA Loma Linda
University
School
12
10
8
6
4
2
0
Count
5
4
3
2
1
scheduling2
Bar Chart
1=No More
2=A Little More
3=Moderately More
4=Significantly More
5=A Great Deal More
34
Figure 9: Additional Education Desired During Residency on Patient Statistical Monitoring
USC UOP UCSF UCLA Loma Linda
University
School
14
12
10
8
6
4
2
0
Count
5
4
3
2
1
monitor2
Bar Chart
For all the respondents combined, moderately to significantly more additional
practice management education during residency was desired. The most preferred
category for additional education was staff hiring, training, evaluation & firing, and the
least was risk management.
Table 13: Amount of Additional Education Desired During Residency on Different Categories
Category All Respondents Combined
Staff hiring, training, evaluation & firing 3.70
Financial indicators, budgeting & analysis 3.62
Contracts & accounts receivable control 3.62
Staff compensation, bonuses & benefits 3.59
Patient insurance plans 3.52
Patient statistical monitoring 3.41
Scheduling principle, design & monitoring 3.39
Practice promotion & marketing 3.35
Business plans & loan applications 3.22
Business & personal insurance 3.19
Practice evaluation & buy-sell procedures 3.18
Associateship principles & procedures 3.04
Goal-setting & leadership skills 3.04
Practice location & demographic analysis 3.03
Office design, equipment & supplies 3.03
Communication & new patient exam/conference 3.00
Personal financial goals, investments & estate/retirement planning 3.00
Risk management 2.78
Overall 3.26
1=No More
2=A Little More
3=Moderately More
4=Significantly More
5=A Great Deal More
35
Current Competency Level (Tables 14-15)
For this section (Table III Parts A and B on the questionnaire), each answer was
assigned a value: Very Low=1, Low=2, Medium=3, High=4, and Very High=5.
Means for the responses from all the alumni of each school were calculated under
the 18 categories of practice management. Overall, USC alumni rated their current
competency level in practice management slightly higher (6 out of 18 categories).
However, none of the categories showed significant difference according to Pearson’s
Chi-Square test.
Table 14: Current Competency Level by School
Category/School LLU UCLA UCSF UOP USC
Practice location & demographic analysis 3.83 3.06 3.2 3.18 3.45
Practice evaluation & buy-sell procedures 3.14 3.5 3.27 2.86 3.45
Associateship principles & procedures 2.91 3.19 3.33 2.86 3.51
Business plans & loan applications 3.45 3.38 3.27 3.09 3.21
Office design, equipment & supplies 3.64 3.81 3.4 3.41 3.73
Scheduling principle, design & monitoring 3.77 3.75 3.73 3.5 3.79
Communication & new patient exam/conference 4.14 4.31 4 4.18 4.36
Practice promotion & marketing 3.55 3.44 3.47 3.41 3.73
Risk management 3.73 3.38 3.67 3.59 3.36
Goal-setting & leadership skills 3.36 3.63 3.6 3.41 3.55
Staff hiring, training, evaluation & firing 2.82 2.94 3.2 3.18 3.09
Staff compensation, bonuses & benefits 3.14 2.94 3.33 3.18 3.15
Patient statistical monitoring 2.95 2.94 3.6 3.09 3.36
Patient insurance plans 2.73 2.31 2.67 2.64 2.81
Financial indicators, budgeting & analysis 3.09 3.19 3.2 3.05 3.33
Contracts & accounts receivable control 3.14 3.44 3.33 3.14 3.24
Business & personal insurance 3.45 3.56 3.53 3.41 3.39
Personal financial goals, investments & estate/retirement planning 3.5 3.6 3.2 3.36 3.33
Overall 3.35 3.35 3.39 3.25 3.44
For all the respondents combined, medium to high current competency level in
practice management was indicated overall (mode=medium). The current competency
36
level was rated the lowest in patient insurance plans and highest in communications &
new patient exam/conference.
Table 15: Current Competency Level on Different Categories
Category All Respondents Combined
Patient insurance plans 2.63
Staff hiring, training, evaluation & firing 3.05
Staff compensation, bonuses & benefits 3.15
Associateship principles & procedures 3.16
Financial indicators, budgeting & analysis 3.17
Patient statistical monitoring 3.19
Practice evaluation & buy-sell procedures 3.24
Contracts & accounts receivable control 3.26
Business plans & loan applications 3.28
Practice location & demographic analysis 3.34
Personal financial goals, investments & estate/retirement planning 3.40
Business & personal insurance 3.47
Goal-setting & leadership skills 3.51
Practice promotion & marketing 3.52
Risk management 3.55
Office design, equipment & supplies 3.60
Scheduling principle, design & monitoring 3.71
Communication & new patient exam/conference 4.20
Overall 3.36
Difference between Initial and Current Competency Levels (Tables 16-17, Figure 10)
Overall, the difference between the perceived initial and current competency
levels is the least for USC alumni (12 out 18 categories) and the most for LLU alumni.
This difference is statistically significant (p=.004) according to Dunnett’s T-3 Post Hoc
Test. It corresponds to the facts that 1) the initial competency level on practice
management upon graduation was rated the highest among USC alumni and the lowest
among LLU alumni, and 2) there is no significant difference on their perceived current
competency levels on practice management.
37
Table 16: Difference between Initial and Current Competency Levels by School
Category/School LLU UCLA UCSF UOP USC
Practice location & demographic analysis 1.59 0.5 0.6 1.13 0.18
Practice evaluation & buy-sell procedures 0.9 1.31 0.6 0.54 0.55
Associateship principles & procedures 0.77 0.94 0.26 0.54 0.61
Business plans & loan applications 1.16 1.63 1.13 1.27 0.71
Office design, equipment & supplies 1.5 1.93 0.87 1.23 0.52
Scheduling principle, design & monitoring 1.77 1.81 0.93 1.45 0.46
Communication & new patient exam/conference 1.38 1.37 0.6 1.04 0.79
Practice promotion & marketing 1.65 1.06 1.07 1.05 0.7
Risk management 1.02 0.13 0.87 0.73 0.26
Goal-setting & leadership skills 0.88 1 0.87 0.86 0.42
Staff hiring, training, evaluation & firing 1.2 1.38 1.27 1.36 0.79
Staff compensation, bonuses & benefits 1.62 1.44 1.6 1.32 1.05
Patient statistical monitoring 0.71 1 1.53 1.27 0.73
Patient insurance plans 1.4 0.81 1.14 1.23 0.94
Financial indicators, budgeting & analysis 1.52 1.13 1.2 1.41 0.8
Contracts & accounts receivable control 1.52 1.63 1.46 1.69 0.94
Business & personal insurance 1.55 1.12 1 1.5 0.46
Personal financial goals, investments &
estate/retirement planning
1.64 1.04 0.67 1.13 0.56
Overall 1.32 1.18 0.98 1.15 0.64**
* p<.05, ** p<.01, *** p<.001
Figure 10: Overall Difference between Initial and Current Competency Levels by School
38
For all the respondents combined, the difference between the perceived initial and
current competency levels is the least in risk management and the greatest in contracts
and account receivable.
Table 17: Difference between Initial and Current Competency Levels on Different Categories
Category All Respondents Combined
Risk management 0.602
Associateship principles & procedures 0.624
Practice evaluation & buy-sell procedures 0.78
Practice location & demographic analysis 0.8
Goal-setting & leadership skills 0.806
Personal financial goals, investments & estate/retirement planning 1.008
Communication & new patient exam/conference 1.036
Patient statistical monitoring 1.048
Patient insurance plans 1.104
Practice promotion & marketing 1.106
Business & personal insurance 1.126
Business plans & loan applications 1.18
Staff hiring, training, evaluation & firing 1.2
Office design, equipment & supplies 1.21
Financial indicators, budgeting & analysis 1.212
Scheduling principle, design & monitoring 1.284
Staff compensation, bonuses & benefits 1.406
Contracts & accounts receivable control 1.448
Overall 1.054
Value of Additional Resources Used Since Graduation (Tables 18-19, Figures 11-17)
For this section (Table IV on the questionnaire), each answer was assigned a
value: Not Used=1, Not Valuable=2, Mild=3, Moderate=4, Very Valuable=5.
Means for the responses from all the alumni of each school were calculated under
the seven types of resources. Overall, all the schools rated additional resources used
since graduation moderately valuable (mode=moderate, mean range=3.86-4.06).
39
Table 18: Value of Additional Resources Used Since Graduation by School
Resources/School LLU UCLA UCSF UOP USC
Professional meetings 4.14 4.06 4.13 4.05 4.06
Specific CE courses 4.23 4.13 4.4 4.14 4.06
Literature (books/journals/newsletters) 4.09 3.69 3.87 3.82 3.48
Study clubs 3.36 3.13 3.07 3.73 3.24
Consultants, accountants, lawyers 3.95 3.63 3.93 3.86 4.3
Visiting other offices 3.91 3.56 3.4 3.55 3.42
Personal experience over time 4.73 4.8 4.8 4.68 4.67
Overall 4.06 3.86 3.94 3.98 3.89
For all the respondents combined, study clubs are the least and personal
experience over time the most valuable (mode= very valuable).
Table 19: Value of Different Resources Used Since Graduation
Resources All Respondents Combined
Study clubs
3.31
Visiting other offices
3.57
Literature (books/journals/newsletters)
3.79
Consultants, accountants, lawyers
3.93
Professional meetings
4.09
Specific CE courses
4.19
Personal experience over time
4.74
Overall
3.95
Study clubs are the least utilized resources by all the respondents combined,
followed by office visits. Besides personal experience over time, professional meetings
are the most utilized resources.
40
1=LLU
2=UCLA
3=UCSF
4=UOP
5=USC
1=LLU
2=UCLA
3=UCSF
4=UOP
5=USC
1=LLU
2=UCLA
3=UCSF
4=UOP
5=USC
Figure 11: Professional Meetings Figure 12: Specific CE Courses
5 4 3 2
profmtgs
60
50
40
30
20
10
0
Frequency
profmtgs
5 4 3 2 1
courses
60
50
40
30
20
10
0
Frequency
courses
Figure 13: Literature Figure 14: Study Clubs
5 4 3 2 1
literature
60
50
40
30
20
10
0
Frequency
literature
5 4 3 2 1
studyclubs
40
30
20
10
0
Frequency
studyclubs
Figure 15: Consultants, Accountants, Lawyers Figure 16: Visiting Other Offices
5 4 3 2 1
consultants
50
40
30
20
10
0
Frequency
consultants
5 4 3 2 1
visits
40
30
20
10
0
Frequency
visits
Figure 17: Personal Experience over Time
5 4
experience
80
60
40
20
0
Frequency
experience
1=LLU
2=UCLA
3=UCSF
4=UOP
5=USC
41
CHAPTER VI: DISCUSSION
Initial Competency Level upon Graduation
The data that USC alumni rated their initial competency level on practice
management higher (16 out of 18 categories, 6 statistically significant) when compared to
alumni from the other schools allowed us to reject our first null hypothesis: alumni from
a residency with a structured practice management curriculum would not rate their initial
competency level in practice management significantly higher. This finding suggests that
the USC Practice Management Program is perceived to be effective in better preparing its
graduates to enter practice upon graduation. On the other hand, the initial competency
level was rated the lowest among LLU alumni. This could be due to the fact that the
LLU orthodontic program was 10 months shorter than the USC program during the
survey period, therefore incorporating sufficient practice management training into the
LLU curriculum might be difficult due to time constraints.
On average, most respondents rated their initial competency level in practice
management low to medium. This reflects a widespread deficiency in practice
management training during orthodontic residencies, as previously stated in the article
that laid the foundation for this research study (Sinclair, 2001). In particular, the initial
competency level averaged from very low to low in the following five categories, which
reflect considerable deficiencies in the areas of financial preparation and staff
management:
1) Patient insurance plans
2) Contracts and account receivable control
42
3) Financial indicators, budgeting and analysis
4) Staff compensation, bonuses and benefits
5) Staff hiring, training, evaluation and firing
Although USC alumni’s ratings were higher in these categories (significantly
higher in 1 and 3), they still averaged below medium. This suggests that more time and
attention could be devoted in strengthening these aspects of practice management training
for all the schools surveyed, including USC.
All the respondents combined averaged the highest scores (above medium) in the
areas of communication and new patient exam/conference. This could be due to the fact
that communication skills are indispensable in patient care during residency, and new
patient exams/conferences are often conducted by orthodontic residents. This implies a
positive correlation between the amount of practical experience of and the initial
competency level in certain practice management skills upon graduation. This suggests
that practical experience is critical and that giving residents practical experience in the
offices of ―mentor‖ orthodontists during their training may be a very valuable addition to
a practice management program.
Additional Practice Management Training Desired During Residency
Our findings under this section strongly echo the ones above, which allowed us to
reject our second null hypothesis: alumni from a residency with a structured practice
management curriculum retrospectively would not desire significantly less additional
practice management training during residency than alumni from other programs. USC
alumni retrospectively desired the least (17 out of 18 categories, 2 statistically
43
significant) and LLU the most additional practice management training during residency.
On average, USC alumni desired a little to moderately more training, and alumni from
the other four schools desired moderately to significantly more training. This also
suggests that practice management skills are deemed important and valuable by
practicing orthodontists, who would like to have received additional training in the areas
that they felt less competent in. This sentiment is also shared by residents of various
dental specialties (Houlberg, 2008).
Interestingly, all respondents combined desired the most additional training in the
same five categories that they felt the least competent in, with slight variation in the
order. Although less than alumni from the other four programs, USC alumni also desired
moderately to significantly more additional training in these categories. Therefore, these
areas should be covered more in depth when implementing or improving the practice
management curriculum in orthodontic residencies, especially for shorter programs that
may not permit sufficient coverage on all the practice management topics.
Current Competency Level and Career Success
Surprisingly, all the respondents combined averaged only medium to high on their
perceived current competency level in most categories after at least five years in practice.
This implies room for improvement and continued interest in this subject among
practicing orthodontists, as reflected by the high response rate. In addition, four out of
five categories mentioned above (contracts and accounts receivable control replaced by
associateship principles and procedures) remain the same categories most respondents
still feel the least competent in. This implies that these practice management skills are
44
not easy to master, and there may be less information available for continuing education.
Again, these areas should be emphasized when incorporating a practice management
curriculum into an orthodontic residency or structuring continuing education program for
alumni.
Contrary to our expectation, USC alumni’s rating of their current competency
level in practice management was not significantly higher than that of alumni from the
other four schools. This indicates that over time, alumni from the other schools seem to
have caught up. Therefore, we had to accept the third null hypothesis that a structured
practice management curriculum does not lead to a higher rating of current competency
level.
Several possibilities might have contributed to the absence of significant
difference in the areas of gross income and practice success. First of all, alumni from the
other four schools might have spent more unguided effort after graduation to learn about
practice management, because the practice management curriculum during their
residency was less structured.
On the other hand, the USC Practice Management Program might have exerted its
most beneficial impact during the early years of the USC alumni’s careers, which was not
investigated in this study. Additionally, although USC alumni received more didactic
training on practice management, the office visitation and study club programs (Sinclair,
2001) to reinforce conceptual knowledge with concrete applications were less
emphasized in the USC Practice Management Program and may be allocated more
curricular time in the future.
45
Difficulty in directly entering private practice due to market saturation and
accruing financial pressure from educational loans might also play a role in our findings.
USC alumni might not be able to apply the knowledge learned during residency soon
after graduation; therefore the advantages USC Practice Management Program provided
to its residents might not be fully realized. One USC alumnus commented on the
returned survey: ―The problem is that if you do not use the tools that you learned soon
after you graduate, it is hard to use them after 10 years when the concepts are already old.
It's hard to be an owner as soon as you graduate. Most of us became associates first."
This reinforced the need for follow-up practice management programs offered to alumni
perhaps every five years.
One LLU alumnus commented regarding increased competition and market
saturation: ―Residents need to know they are entering an extremely competitive and
saturated field. They will spend an extraordinary time trying to find patients to fill their
schedules. The biggest benefit to residents would be reducing the ortho residency class
size, since many residents are having/will have difficulty finding a job in private
practice.‖ According to the Bureau of Labor Statistics, there will be a 20% increase in
the number of orthodontists in the United States (7,700 to 9,200) within the next decade
(2008-2018) (Occupational Outlook Handbook, 2010-11 Edition).
The oversupply of orthodontic graduates may remain a problem in the future,
since orthodontic departments are one of the most profitable in dental schools and are less
likely to be downsized or eliminated. The current economic downturn seems to only
exacerbate the situation, as reflected in the 2009 JCO Orthodontic Practice Study:
46
With the current recession in full swing at the end of 2008—the year reflected in
the income data for this Practice Study—the orthodontic economy was more
stagnant than at any time since these surveys began in 1981. Over the past two
years, median gross income rose by only 4%, while median net income declined
for the first time. As a result, lower percentages of practices reported growth in
gross income and case starts than ever before. Furthermore, a higher percentage
of respondents than in any previous survey reported being ―not busy enough‖.
When this survey was conducted in early 2009, respondents were more
pessimistic about the following year than at any time in the past three decades.
This seems to indicate that the overall results of the 2011 Practice Study are
unlikely to be much improved over the data in the current report. Still, as in every
Study to date, some practices were more successful than others in generating new
patients and net income. These tended to be the ones that made the best use of
management and practice-building methods and routinely delegated chairside and
administrative tasks to their staff members. Considering that 89% of all
respondents were not busy enough or at least ―did not feel overworked‖, such
methods might provide a template for finding the growth potential within a
practice (Keim, 2010).
Consequently, practice management should be considered an important
component of orthodontic training. The current curriculum at USC can be used as a
template to implement such changes. Moreover, young orthodontists may continue to
equip themselves for entering a competitive practice environment by staying current with
the latest developments and techniques in orthodontic practice management.
Additional Major Findings
Difference between Initial and Current Competency Levels
Three of the five categories mentioned above also displayed the greatest
differences between the perceived initial and current competency levels of all the
respondents combined: 1) contracts and accounts receivable control, 2) staff
compensation, bonuses and benefits, and 3) financial indicators, budgeting and analysis.
It is possible that these areas crucial to daily operation of an orthodontic practice received
the most attention from orthodontists to increase their competency level.
47
Practice’s Gross Annual Income
Similar to the figure reported in the 2009 JCO Orthodontic Practice Study, the
median gross annual income in our study was between 1-1.5 million dollars for all the
respondents combined, UCSF, UOP, and USC alumni. It was slightly higher for UCLA
and lower for LLU alumni.
The most commonly reported gross annual income in our study, on the other
hand, was higher among LLU and UCLA alumni, who reported a higher number of days
worked per month than alumni from the other 3 schools. Therefore, it is possible that
those who worked more days per month grossed more. However, the most reported
percentage overhead for LLU and UCLA alumni was also higher. Consequently, their
net income might not be higher.
One has to keep in mind, however, that these differences only demonstrate trends
and are not statistically significant.
Number of Weeks Taken Off Per Year
Among the background information surveyed in our study, alumni from different
schools showed significant difference only on the number of weeks taken off per year:
USC alumni take significantly fewer weeks off per year than alumni from the other
schools (especially UOP alumni, who seemed to compensate for the fewer number of
working weeks by seeing a higher average number of patients per treatment day).
This finding could be related to the fact that the USC orthodontic program has one
of the highest tuition and fees in the nation. For example, according to the 2008-2009
Survey of Advance Dental Education, by the end of the residency USC graduates can be
48
as much as $222,000 more in debt than UCLA residents. This financial pressure might
have contributed to the decision of most USC alumni to take fewer weeks off per year.
Table 20: 2008 Total Stipend or Tuition/Fees of Orthodontic Residency Programs in California
School Stipend Tuition/Fees
UCLA $42,000 0
UCSF 0 $40,928
LLU 0 $88,113
UOP 0 $142,924
USC 0 $180,000
Contentment with Work Schedule/Income Level/Lifestyle
It is also interesting to note that a higher though not statistically significant
percentage of alumni from the public schools (UCLA and UCSF) are content with their
work schedule, income level, and lifestyle. One may argue that this is purely subjective,
as illustrated by a comment from a USC alumnus ―Are we ever content?‖ However, it is
not illogical to speculate that financial pressure from educational loans accrued during
residency might have contributed to this finding as well.
Additional Resources Utilized After Graduation
Personal experience over time is unanimously the most valuable resource in
improving practice management skills. One USC alumnus commented: "These things
need to be learned by first-hand experience. Too much training would not have been
helpful. Training now is the most helpful!!"
Continuing education courses and professional meetings were frequently utilized
and rated valuable as well. The American Association of Orthodontists through its
Distance Learning Program offers various on-line lectures and CD’s covering myriads of
topics such as strategic business planning and balancing inventory. The AAO Annual
49
Sessions are also well attended and the lectures made available for purchase in the DVD
format (AAO, 2010). These resources are good starting points for those who wish to
further their learning in practice management.
Limitations
A survey study was chosen as the best methodology to conduct this research, as it
is an efficient and economical way of collecting specific information of interest from
respondents located across a wide range of geographic areas. Statistical techniques were
used to determine statistical significance. However, as in any survey study, the accuracy
or veracity of the responses could not be confirmed. The results depended on
respondents’ motivation, honesty, memory, and interpretation of the questions/answers.
Structured surveys, particularly those with closed-ended questions, may have low validity
and vague data set when answer choices are limited or generalized.
In addition, errors due to non-response may exist; people who chose to respond
may be different from those who chose not to, thus biasing the results. However, our
findings on the respondents’ practice background information are similar to that of the
2009 JCO Practice Survey Study, which reported 545 responses from orthodontists across
the nation (Keim, 2009). Therefore, it is believed that respondents in our study represent
well the practicing orthodontists we aimed to study.
Another limitation was the sample size of this study, although the response rate
(45%) is considered high among survey studies (typically less than 10%). Although more
orthodontists graduated between 1995 and 2005 from the five schools participating in this
study, only 251 surveys were mailed after eliminating those who now practice in other
50
countries and those who trained under the UCLA joint pedo-ortho program. In addition,
a good portion of the alumni contact information provided by the five orthodontic
departments was not current, resulting in much effort to mail the surveys to correct
addresses and failed delivery to five orthodontists. Lastly, despite two complete
mailings, the lack of financial incentive to complete the survey and our inability to follow
up with those who did not respond due to the anonymous and confidential nature of this
study also served as obstacles to increase the sample size.
Future Directions
To further investigate the impact of practice management curriculum during the
early years of new graduates’ careers, a study surveying alumni who graduated within the
last three years from all orthodontic programs in the U.S. should be designed.
In addition, after practice management curriculums are modified in the future, this
study can be repeated to evaluate the impact of changes such as 1) strengthening the
office visitation and study club programs of the USC Practice Management Program, and
2) placing more emphasis on the subjects with the lowest initial competency level, the
most additional training desired during residency, and the lowest current competency
level.
51
CHAPTER VII: CONCLUSIONS
1. When compared to alumni from other orthodontic residencies (LLU, UCLA,
UCSF, UOP), alumni from a residency (USC) with a structured practice
management curriculum:
1) Rated their initial competency level in practice management higher (16
out of 18 categories, 6 statistically significant),
2) Retrospectively desired less (17 out of 18 categories, 2 statistically
significant) additional practice management training during residency,
3) Did not rate their current competency level in practice management
significantly higher.
2. There is a widespread deficiency in practice management training during
orthodontic residencies especially in the areas of financial preparation and
staff management. Most respondents rated their initial competency levels in
practice management very low to low and desired moderately to significantly
more additional education during residency in these areas, which should be
emphasized when implementing or modifying the practice management
curriculum.
3. The USC Practice Management Program was perceived to be effective in
better preparing the residents for practice upon graduation and may be used as
a template to implement such changes.
4. Practical experience is critical to improving the initial competency level in
practice management; therefore increasing exposure during residency to well-
52
managed practices where residents can observe or apply the management
skills first-hand may be very valuable.
5. Even after five years in practice, most respondents still do not feel very
competent in practice management. Offering continuing education programs
especially in the areas of financial preparation and staff management may be
beneficial to alumni.
53
REFERENCES
AAO 2009 distance learning education catalog.
http://www.aaomembers.org/Education/upload/2009-Education-AAO-Distance-
Learning.pdf
ADA 2008 Survey of New Dentists. 2009 Oct.
http://www.ada.org/ada/prod/survey/publications_newreports.asp#newdent
ADA 2008-2009 Survey of Advanced Dental Education. 2010 Jan.
http://www.ada.org/ada/prod/survey/survey_advanced_ed.pdf
Align Technology. Fourth quarter and fiscal 2009 financial report. GlobeNewswire, Inc.
2010 Jan; 1-13.
http://files.shareholder.com/downloads/ALGN/855309913x0x346929/32ca060b-797b-
4c7a-abc4-b198b8cf91e0/ALGN_News_2010_1_27_Financial_Releases.pdf
Atta AE. Total quality management in orthodontic practice. Am J Orthod Dentofacial
Orthop. 1999; 116:659-60.
Bruner MK, Hilgers KK, Silveira AM, Butters JM. Graduate orthodontic education: The
residents’ perspective. Am J Orthod Dentofacial Orthop. 2005;128:277-82
Coats MJ, Straja SR, Wiser G, Heckman H, Saavedra W, Tuncay OC. Defining
characteristics of financially successful orthodontists. Am J Orthod Dentofacial Orthop.
2000; 118:18-23.
Commission on Dental Accreditation. Accreditation standards for advanced specialty
education programs for orthodontics and dentofacial orthopedics. Chicago: American
Dental Association. 2008; 1-29.
Currier JH. Letters to the Editor: Provocative thoughts about tomorrow’s orthodontists
today. Am J Orthod Dentofacial Orthop. 2004 Jan; 125(1): 20-21A.
Educational update: Excellence in postdoctoral orthodontic education. Am J Orthod
Dentofacial Orthop. 1996 Jan; 104.
Houlberg BJ. Dental residents' perceptions of practice and patient management training
during postgraduate education. J Dent Educ. 2008 Jun; 72(6):643-52.
Hsu S. MS Thesis: An evaluation of the characteristics of successful orthodontic
practitioners. The Graduate School, USC. 1996; 1-120.
54
Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO Orthodontic practice study:
Part 1 Trends. J Clin Orthod. 2009 Oct; 43(10):625-34.
Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO Orthodontic practice study:
Part 4 Additional breakdowns. J Clin Orthod. 2010 Jan; 44(1): 19-27.
Keim RG, Sinclair PM. Orthodontic graduate education survey, 1983-2000. Am J Orthod
Dentofacial Orthop. 2002 Jan, 121(1):2-8.
Keith O, Proffit WR. Orthodontic training: The residents' perspective. Am J Orthod
Dentofacial Orthop. 1994; 106:649-53.
Kharbanda OP. Global issues with orthodontic education: a personal viewpoint. J
Orthod. 2006; 33: 237–241.
Masella RS, Meister M. Challenges to postdoctoral orthodontic education. Am J Orthod
Dentofacial Orthop. 2002 Aug; 122(2):221-5.
Noble J, Hechter FJ, Karaiskos NE, Wiltshire WA. Resident evaluation of orthodontic
programs in the United States. J Dent Educ. 2009 Nov; 73(11):1286-92.
Sinclair PM, Grady EM. Preparing to practice and manage: A program for educating
orthodontic residents in practice management. Am J Orthod Dentofacial Orthop 2001;
120:2-8.
Smith GP. MS thesis: Factors in the financial success of orthodontists. The Graduate
School, USC. 2009; 1-57.
Turpin DL. Debt a fact of life for postgraduate students. Am J Orthod Dentofacial Orthop
2007; 132:275-6.
55
APPENDIX A - QUESTIONNAIRE
Note: Formatting Adjusted from the Original in Order to Fit in Required Margins
Please complete all questions and return before Nov 1. All answers will remain completely anonymous.
BACKGROUND & STAGE OF PRACTICE
School and Year of Graduation (please answer both):
-1997
-2000
-2003
-2005
Mode(s) of Practice (may check more than one answer):
What was the practice’s average gross annual income for the past 2 years (2007- 2008)?
$250k
-$500k
-$1 million
-$1.5 million
What was the practice’s overhead as a percentage of the gross annual income for the past 2 years (2007-2008)?
-50%
-60%
Days worked per month (including patient care and practice management/marketing):
-15 days
-20 days
Average number of patients seen per treatment day:
-60 patients
-80 patients
-100 patients
How many weeks do you take off per year for vacation and continuing education?
-4 weeks
-6 weeks
Are you content with your current (may check more than one answer):
Please turn over for page 2.
56
PRACTICE MANAGEMENT EDUCATION
Table I Part A. Based on the practice management education you received during your residency, please rank how competent you felt upon graduation
in the following categories. Please use a check (√) for your responses.
Very Low Low Medium High Very High
Practice location & demographic analysis
Practice evaluation & buy-sell procedures
Associateship principles & procedures
Business plans & loan applications
Office design, equipment & supplies
Scheduling principle, design & monitoring
Communication & new patient exam/conference
Practice promotion & marketing
Risk management
Goal-setting & leadership skills
Table I Part B. Based on the practice management education you received during your residency, please rank how competent you felt upon graduation in
the following categories.
Very Low Low Medium High Very High
Staff hiring, training, evaluation & firing
Staff compensation, bonuses & benefits
Patient statistical monitoring
Patient insurance plans
Financial indicators, budgeting & analysis
Contracts & accounts receivable control
Business & personal insurance
Personal financial goals, investments & estate/retirement planning
Table II Part A. Based on your current experience, please rate how much more practice management education you would have liked to have received
during your residency in the following categories.
No More A Little
More
Moderately
More
Significantly
More
A Great Deal More
Practice location & demographic analysis
Practice evaluation & buy-sell procedures
Associateship principles & procedures
Business plans & loan applications
Office design, equipment & supplies
Scheduling principle, design & monitoring
Communication & new patient exam/conference
Practice promotion & marketing
Risk management
Goal-setting & leadership skills
2 of 3
57
Table II Part B. Based on your current experience, please rate how much more practice management education you would have liked to have received
during your residency in the following categories.
No More A Little
More
Moderately
More
Significantly
More
A Great Deal More
Staff hiring, training, evaluation & firing
Staff compensation, bonuses & benefits
Patient statistical monitoring
Patient insurance plans
Financial indicators, budgeting & analysis
Contracts & accounts receivable control
Business & personal insurance
Personal financial goals, investments & estate/retirement planning
Table III Part A. Please rate your current competency level in the following categories:
Very Low Low Medium High Very High
Practice location & demographic analysis
Practice evaluation & buy-sell procedures
Associateship principles & procedures
Business plans & loan applications
Office design, equipment & supplies
Scheduling principle, design & monitoring
Communication & new patient exam/conference
Practice promotion & marketing
Risk management
Goal-setting & leadership skills
Table III Part B. Please rate your current competency level in the following categories:
Very Low Low Medium High Very High
Staff hiring, training, evaluation & firing
Staff compensation, bonuses & benefits
Patient statistical monitoring
Patient insurance plans
Financial indicators, budgeting & analysis
Contracts & accounts receivable control
Business & personal insurance
Personal financial goals, investments & estate/retirement planning
Table IV. Please rate the value of the following resources that you have used since graduation:
Not Used Not Valuable Mild Moderate Very Valuable
Professional meetings
Specific CE courses
Literature (books/journals/newsletters)
Study clubs
Consultants, accountants, lawyers
Visiting other offices
Personal experience over time
THANK YOU VERY MUCH FOR YOUR TIME.
3 of 3
58
APPENDIX B – FIRST MAILING COVER LETTER
Note: Formatting Adjusted from the Original in Order to Fit in Required Margins
October 15, 2009
Dear Colleague,
Enclosed you will find a survey to assess the adequacy and effectiveness of practice management
curriculum in orthodontic residencies. This is a collaboration of the Journal of Clinical
Orthodontics and all five orthodontic departments in California (Loma Linda University,
University of California at Los Angeles, University of California at San Francisco, University of
Pacific, and University of Southern California).
As part of a Master’s thesis and a JCO publication, we aim to evaluate how practice management
training impacts an orthodontist’s 1) initial preparedness to enter practice, 2) current confidence
level in managing an efficient practice, 3) lifestyle, and 4) financial success. Would you please
take the next three to five minutes to complete the survey? Your responses will remain
completely anonymous, as all surveys will be returned to the JCO office. A self-addressed,
stamped return envelope is enclosed for your convenience.
The Information Sheet is enclosed in compliance with the Institutional Review Board (IRB)
regulating research studies involving human subjects and should not be returned with the survey.
We would appreciate your participation in this effort to determine whether practice management
should be considered an important component of education in orthodontic residencies in the
future. Thank you for your valuable time in completing the survey. Please return by November
7
th
.
Sincerely,
Vivian Lee, DDS Robert Keim, DDS, EdD
Orthodontic Resident, Class of 2010 Editor-in-Chief
USC School of Dentistry Journal of Clinical Orthodontics
PLEASE COMPLETE THIS SURVEY AND RETURN BEFORE NOVEMBER 7, 2009.
THANK YOU.
59
APPENDIX C – SECOND MAILING COVER LETTER
Note: Formatting Adjusted from the Original in Order to Fit in Required Margins
November 25, 2009
Dear Colleague,
One month ago a survey assessing the adequacy and effectiveness of practice management
curriculum in orthodontic residencies was mailed to you. We have received several responses
from your class and are thankful to those who replied. However, if you have not returned the
survey, could you please take the next 3-5 minutes to fill in the survey and help us complete the
data for your class? There is no way for us to determine who has not replied due to the anonymity
of this project. Therefore, please ignore this letter if you have already mailed back your response.
As a reminder, this project is a part of a Master’s thesis and a JCO publication to evaluate how
practice management training impacts an orthodontist’s 1) initial preparedness to enter practice,
2) current confidence level in managing an efficient practice, 3) lifestyle, and 4) financial success.
This is a collaboration of the Journal of Clinical Orthodontics and all five orthodontic
departments in California (LLU, UCLA, UCSF, UOP, and USC).
We would appreciate your participation in this effort to determine whether practice management
should be considered an important component in orthodontic training in the future. Your
responses will remain completely anonymous, as all surveys are returned to the JCO office. A
self-addressed, stamped return envelope is enclosed for your convenience. The Information Sheet
is enclosed in compliance with the Institutional Review Board (IRB) regulating research studies
involving human subjects and should not be returned with the survey.
Thank you for your valuable time and effort in completing the survey. PLEASE RETURN THE
SURVEY BY DECEMBER 15
TH
.
Sincerely,
Vivian Lee, DDS Robert Keim, DDS, EdD
Orthodontic Resident, Class of 2010 Editor-in-Chief
USC School of Dentistry Journal of Clinical Orthodontics
PLEASE COMPLETE THIS SURVEY AND RETURN BEFORE NOVEMBER 7, 2009.
THANK YOU.
60
APPENDIX D – INFORMATION SHEET
Note: Formatting Adjusted from the Original in Order to Fit in Required Margins
UNIVERSITY OF SOUTHERN CALIFORNIA
GRADUATE ORTHODONTICS
INFORMATION SHEET FOR NON-MEDICAL RESEARCH
ASSESSMENT OF PRACTICE MANAGEMENT EDUCATION IN ORTHODONTIC
RESIDENCIES
You are asked to participate in a research study conducted by Vivian Lee, DDS; Robert Keim,
DDS, EdD; and Glenn Sameshima, DDS, PhD from the Graduate Orthodontic Department at the
University of Southern California for a Masters’ thesis. You were selected as one of 300 possible
participants in this study because you graduated from LLU, UCLA, UCSF, UOP, or USC
between 1995 and 2005. Your participation is voluntary.
PURPOSE OF THE STUDY
We aim to assess the adequacy and effectiveness of practice management curriculum in
orthodontic residencies.
PROCEDURES
You are asked to complete the enclosed survey and return it in the self-addressed, stamped
envelope. Completion and return of the survey will constitute consent to participate in this
research project.
POTENTIAL RISKS AND DISCOMFORTS
There is no anticipated risk or discomfort. You may be inconvenienced by taking time to
complete the survey or feel uncomfortable answering certain questions. Those questions can be
left blank. However, the survey is anonymous and completely confidential. There is no way to
tie answered questions back to a particular doctor.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
You may not directly benefit from your participation in this research study. However, it is
anticipated that the results will be published in the Journal of Clinical Orthodontics. By reading
the article, you may learn whether practice management should be considered as an important
component of education in orthodontic residencies in the future. A structured practice
management curriculum can provide opportunities for residents and alumni to learn some of the
latest developments and techniques in orthodontic practice management.
PAYMENT/COMPENSATION FOR PARTICIPATION
You will not receive any payment for your participation.
POTENTIAL CONFLICTS OF INTEREST
The expenses for the study are being paid by the USC Graduate Orthodontic Department.
61
CONFIDENTIALITY
Only the school and year of graduation will be collected to differentiate the control
groups. Your name, address or other identifying information will not be collected.
The returned surveys will be stored in the investigator’s office in a locked cabinet and
shredded once data is compiled into an Excel spreadsheet. Only members of the research
team will have access to the data, which will be stored in a password protected computer
for three years upon completion of the study and then destroyed.
When the results are published or discussed in conferences, no information will reveal
your identity since no individual identifiers will be collected.
PARTICIPATION AND WITHDRAWAL
You can choose whether to be in this study or not. If you volunteer to be in this study, you may
withdraw at any time without any consequences. You may also refuse to answer any questions
you don’t want to answer and still remain in the study. The investigator may withdraw you from
this study if circumstances warrant doing so. However once a survey is submitted, it cannot be
returned because there is no way to determine which survey is yours.
ALTERNATIVES TO PARTICIPATION
Your alternative is to not participate.
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without penalty. You
are not waiving any legal claims, rights or remedies because of your participation in this study. If
you have any questions about your rights as a study subject, wish to speak with someone
independent of the research team regarding this study, or are unable to reach the research staff,
please contact the University Park IRB, Office of the Vice Provost for Research Advancement,
Stonier Hall, Room 224a, Los Angeles, CA 90089-1146, (213) 821-5272 or upirb@usc.edu.
IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about the research, please feel free to contact:
Dr. Vivian Lee, 925 West 34th Street, DEN 318, Los Angeles, CA 90089
Dr. Robert Keim, 925 West 34th Street, DEN 312, Los Angeles, CA 90089
Dr. Peter Sinclair, 925 West 34th Street, DEN 312, Los Angeles, CA 90089
Date of Preparation: July 14, 2009
USC UPIRB #: UP- 09-00188
Abstract (if available)
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Asset Metadata
Creator
Lee, Vivian W.
(author)
Core Title
The effectiveness of practice management education in orthodontic residencies: the alumni's perspective
School
School of Dentistry
Degree
Master of Science
Degree Program
Craniofacial Biology
Publication Date
04/30/2010
Defense Date
03/25/2010
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
alumni's perspective,OAI-PMH Harvest,orthodontic residencies,practice management education
Place Name
California
(states)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Keim, Robert G. (
committee chair
), Moon, Holly (
committee member
), Paine, Michael (
committee member
)
Creator Email
vivianwei@yahoo.com,vivianweilee@gmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-m2978
Unique identifier
UC1304478
Identifier
etd-Lee-3651 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-308278 (legacy record id),usctheses-m2978 (legacy record id)
Legacy Identifier
etd-Lee-3651.pdf
Dmrecord
308278
Document Type
Thesis
Rights
Lee, Vivian W.
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Repository Name
Libraries, University of Southern California
Repository Location
Los Angeles, California
Repository Email
cisadmin@lib.usc.edu
Tags
alumni's perspective
orthodontic residencies
practice management education