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Letter to the Editor
By: James H. Spencer, III, County Administrator, Tazewell County Administrator & David W. Olive, President, Bluefield College
February 18, 2013
Dr. Kirk Norbo, a Northern Virginia dentist and president of the Virginia Dental Association, expressed his concerns in an open letter to the public about his reservations regarding the dental school project being developed by Tazewell County and Bluefield College. We regret Dr. Norbo was unable to attend our information meeting held at the College on January 28 because had he done so he would have heard many of his questions answered. Notwithstanding, we appreciate Dr. Norbo’s interest in this project and wish to respond to his comments and concerns in this forum, the one that he chose.
Dr. Norbo stated, “I have a personal experience that makes me either qualified or biased in evaluating the Tazewell project as I was a student at Oral Roberts University School of Dentistry from 1979-1983.” The school opened in 1978 and closed after eight years of operation. Dr. Norbo is concerned that the proposed new dental school will have a similar demise.
Whether Dr. Norbo is aware or not, many issues contributed to the closing of Oral Roberts School of Dentistry. That dental school significantly missed its enrollment targets. The school’s enrollment target was 50 students in each class, but the first class held only 25 students. The subsequent years apparently were not better, as the school had just graduated approximately 100 students before it closed. Additionally, Oral Roberts University was staggering under tremendous debt. Along with the dental school, the University had opened a law school and a medical school, having constructed a new hospital. The University closed the medical school and hospital as part of a plan to eliminate a $25 million debt. Not only did Oral Roberts close the medical school, the University closed its law school and dental school, too. The Bluefield College School of Dental Medicine will not be encumbered with debt as was the Oral Roberts school. Also, based on the national dental school applicant-per-enrollee ratio of 2.8 to 1.0 (as of 2010-11, reported by the ADEA), Bluefield College’s diligence in recruiting should be successful to achieve a positive launch of our dental school.
The first question posed by Dr. Norbo was whether a dental school should be a driver for economic development. He contends, “[W]hen the focus of any dental school revolves around income production, the profession and ultimately patient care is in big trouble.” As the planners of this new dental school have said from the beginning, this project – first and foremost – will enhance the oral health of children and families, addressing a longstanding problem in our rural communities. In addition, we acknowledge that this school, like many higher education institutions, will be an economic driver in creating new, high-paying jobs, stimulating new and existing businesses, and serving as a catalyst as the first entity to open in the new Bluestone Business & Technology Center. Finally, the dental school will provide greater access to dental education, especially for those throughout Central Appalachia who even now must leave home to acquire this education and, for various reasons, often do not return. And, perhaps young people in our area who would have never thought about the dental profession will give the profession consideration.
The next question posed was whether student indebtedness arising from borrowing to attend our dental school would drive graduates to suburban areas. Certainly, a dental degree is one of the most expensive graduate degrees a student may choose to pursue, and dental students historically have graduated with considerable debt. The 2010 survey by the American Dental Education Association indicated the average amount of outstanding educational loans reported by graduating dental students for their dental education was $200,111. The average debt upon graduation was lower at public dental schools ($177,040) than at private dental schools ($236,224), mainly because of the tremendous financial state subsidies received by public schools.
The School of Dental Medicine plans to prepare dentists for a primary care dental practice in rural or otherwise underserved communities and will not have a focus on graduating dentists to enter careers in bench research or dental subspecialties. While we expect some graduates will stay and serve in our rural areas scattered throughout Southside and Southwest Virginia, certainly not all graduates will. Graduates who have a heart for the people in our part of Appalachia will either purchase existing practices from retiring dentists, seek employment in any one of several community health centers that have been unsuccessful in recruiting dentists, or open new practices in areas underserved.
Without question, a tremendous need exists. The vast majority of the Commonwealth has 65 licensed dentists per 100,000 residents, but in Southwest Virginia that ratio is only 33 dentists per 100,000 – one-half the statewide norm. In addition to attracting students who have a heart for service, we will be seeking partners to offer scholarships or loan forgiveness, such as Tazewell County’s scholarship commitment to graduates who choose to serve in rural communities. Other scholarship programs exist to help dental students, including the National Health Service Corps Scholarship program, a program that pays tuition, fees, other education costs, and a living stipend, in exchange for at least two years of service at an approved facility in a high-need Health Professional Shortage Area.
So even though the debt is significant, and while the school is committed to seeking opportunities to assist students in minimizing debt, the average annual salary of dentists in the U.S. exceeds that of U.S. pediatricians, family practitioners and general internists. We recognize, however, that a dental practice in rural Southside or Southwest Virginia will not place a dentist in the upper earning brackets. But just as hundreds of other health professionals who work in these rural areas repay their education loans, we believe that the dental students in successful practices will find that the career and profession are worth the investment.
Equally as important, if not more so, will be the dental school’s third- and fourth-year students, who will work with dental faculty to render oral care in underserved areas and to those who are on Medicaid. Our dental school’s clinical experiences that are a part of all dental students’ education will not be in a centralized location, as is the case in most dental educational programs. Rather, they will be located in several “built out” clinics located in rural and underserved regions in Southside and Southwest Virginia, and perhaps extending into neighboring Appalachian states and communities. Our dental school is designed to have a public health research focus and rely on a dispersed clinical experience that benefits residents in rural communities, not just once a year but on an ongoing basis.
Another question raised by Dr. Norbo was, “Will a brand new school in a beautiful, but rural area, be able to compete as competition is fierce and getting fiercer?” While, anecdotally speaking, this competition may be the impression, the data speaks otherwise. The American Dental Education Association notes that, while national dental school enrollment has increased over the past 10-year period 2001-02 to 2010-11, the number of applicants has increased even more. Enrollment at dental schools has risen from 4,407 to 5,170 (a 17 percent increase), but the number of applicants has risen, as well, from 7,412 to 12,001 (a 62 percent increase). Based on DAT scores and GPA, the applicants appear to be qualified and have the credentials to be successful. Thus, the supply and demand is quite evident and demonstrates room for a new dental program such as the one being developed. With more dentists projected to retire and leave the profession than those entering it in the next 10 years (ADEA), our dental school will be meeting a great national need in preparing the next generation of dental professionals. And further, more people desire to preserve their dentition, finding extractions and dentures a less appealing option than in the past. Therefore, the demand for routine dental services is anticipated to grow.
Dr. Norbo further asked, “How financially sustainable is the model over the mid-long term?” He bases his skepticism about the financial plan of the new dental school (one which he has not yet seen) on a study he refers to as the UVA-Wise study. In fact, there are two studies that have been conducted in recent years. One study was by UVA-Wise to investigate developing a dental school, and the other was a study by VCU investigating the creation of a dental clinic in Wise County. Dr. Norbo refers to the clinic and asks why it wasn’t developed when offered “free money” by the Commonwealth. The VCU study projected start-up costs of $2,643,400, which included construction of the facilities and the installation of dental equipment and office furniture. The study further projected ongoing annual operational costs of $1,041,650, but deemed the clinic would generate revenue of only approximately $150,000 per year. Thus, the study projected that, in order to break even, the clinic would require a minimal subsidy from the state or private funding of $900,000 annually.
The model proposed in the UVA-Wise study is not our model. The County is not building a traditional dental school similar to VCU, as the UVA-Wise study proposed and almost every existing dental school across the country provides. Unlike those models, our plan calls for the use of existing dental resources in the regions served instead of trying to replicate resources that already exist. Our financial model is sustainable and one that has been employed by at least two other successful dental schools in the U.S., as well as having been reviewed by dental experts, including the College’s consultant, Dr. Karen P. West, dean of the UNLV School of Dental Medicine.
While touching somewhat on previous questions, Dr. Norbo’s final question was, “What in the University of Virginia study should be considered?” He then enumerated aspects of concern raised in the UVA-Wise study, specifically:
1. “Demand for dental services is low due to lack of funds to pay providers.” We agree with Dr. Norbo, and we invite him and members of the Virginia Dental Association to advocate along with us on this public health issue. Virginia’s investment in dental services for those of lower economic means is one of the lowest in the country. That’s why third graders in Southwest Virginia are 107 percent more likely to have untreated cavities than is typical for third graders at the statewide level. Let’s work to change policies so that we can improve access to dental care for young and vulnerable other populations.
2. “The recently implemented dental hygiene protocol is working well.” While that dental hygiene protocol is working well to the extent that hygiene services have been expanded in Southwest Virginia, the data details that a significant number of children in our region still lack access to dentists and professional preventive and treatment care.
3. “Graduates settle down where they can make a living.” Again, we don’t disagree. But, does everyone in Southwest Virginia need to move to Northern Virginia or other areas where one can “make a living?” Dr. Norbo now actually is suggesting why a dental school is needed here from an economic development perspective. Secondly, prospective dental students who are solely focused on how much money they will make need not apply at our new dental school. We seek students who see beyond themselves to a world which needs their service.
4. “Recruitment of faculty would be a major challenge.” Yes, and that is why we will pay competitive salaries. This same argument was made as the Appalachian School of Law and Appalachian College of Pharmacy were being envisioned. Faculty who desire to live in large areas with low crime, great outdoor activity options and low cost of living have been successfully recruited and retained by both of these successful institutions of higher education. Secondly, similar to the previous statement, prospective faculty who are solely focused on the money need not apply. Faculty who do come teach at this school will feel, in part, called to serve and live out the mission of the school.
5. “Southwest, VA is an attractive place for all kinds of businesses but is a dental school on of those?” Yes. We invite Dr. Norbo to come visit and see why. In fact, a letter was sent last week to Dr. Norbo inviting him to visit the site of our future facility and review our plan.
We are excited that our dental school will address a significant need not only in Southwest and Southside Virginia, but in other similarly situated underserved communities. We are confident that the business plan is sound for the model developed. And, we are committed to seeing this new school become a reality. We are deeply appreciative of Dr. Norbo’s closing statement – “I know the Virginia Dental Association and the dedicated, loyal dental practitioners stand ready to help and provide any help necessary to make the best decision possible” – and we look forward to partnering with him and members of the VDA in launching this new dental school.
See Dr. Kirk Norbo’s Update on the Bluefield College Dental School