The State Children’s Health Insurance Program (SCHIP) covers about 2 million additional low-income children who do not qualify for Medicaid.² Still other programs support community and migrant health centers and other facilities and medical personnel in locations where low-income people live. Although relatively small compared with Medicaid, these programs extend health care services to many low-income and vulnerable populations.

Four major federal programs other than Medicaid and SCHIP target services or providers to underserved or special populations with poor dental health:

– Health Center program (grant funding under Section 330 of the Public Health Service Act);

– National Health Service Corps (NHSC);

– Indian Health Service (IHS) dental program;

– IHS loan repayment program.

The Health Center program supports community and migrant health centers in medically underserved areas. President Bush’s fiscal year 2003 budget requested almost $1.5 billion for health centers, a $114 million increase from the 2002 allocation and about $280 million above the funding level for fiscal year 2001. The increase for fiscal year 2003 alone provided services to 1 million additional patients around the country. President Bush’s five-year plan will add or expand health centers in 1,200 communities by 2006 and increase the number of patients served annually to more than 16 million (up from 10 million in 2001).

In fiscal year 2002, the first full year of the president’s initiative, the Department of Health and Human Services funded 171 new health center sites and awarded 131 grants to existing centers to help them increase capacity and expand services.³ As part of the expansion plan, all new federally funded community health centers (CHCs) are required to provide dental services.⁴

Governmental incentives to recruit and retain dentists to treat the underserved, such as the scholarship program and loan repayment program operated by the NHSC, have not been completely successful. Too few health care professionals participate, retention rates are low and programs are consistently underfunded.^2,5 In fiscal year 1999, NHSC was able to fill only one of every three vacant dentist positions in underserved areas.² However, fiscal year 2003 congressional appropriations added $64.3 million to the Bureau of Health Professions, which includes the NHSC loan repayment program.⁶ This increase, in conjunction with the CHC expansion grants, will result in expanded loan repayment programs.

No studies have attempted to analyze the reasons for recruitment and retention problems among dentists in community health centers.

	COMMUNITY HEALTH CENTER ORGANIZATION

TOP ABSTRACT COMMUNITY HEALTH CENTER... MATERIALS AND METHODS RESULTS DISCUSSION STUDY LIMITATIONS CONCLUSIONS REFERENCES

 
This study addresses the access to care issue only as it pertains to the CHC. CHCs that have dental components typically employ one or more dentists to provide dental services in the same manner that physicians are employed to provide medical care. In such organizations, which legally are nonprofit corporations, the medical and dental directors report to an executive director and a board of directors. In small clinics that employ only one dentist, the dentist is, by default, the dental director. Larger clinics may employ many dentists or have multiple sites with staff dentists who report to the dental director. In addition to their clinical practice duties, dental directors generally have administrative responsibilities. These responsibilities may include, but are not limited to, attending management team meetings, addressing quality assurance and regulatory compliance issues, addressing patient complaints and conducting audits of records.

Despite the increased funding, however, CHC dental programs cannot meet the needs of the populations they serve.² Reports of dentist vacancies in CHCs persist, and reasons for the difficulty in retaining dentists continue to be the subject of intense speculation. Although work force studies have explored career satisfaction among dentists and physicians,^7,8 no studies have attempted to analyze the reasons for, or prevalence of, recruitment and retention problems among dentists in CHCs. We attempted to answer some of these questions by

– identifying characteristics of dentists who work in CHCs;

– determining the proportion of dentists who intend to remain in CHCs for the remainder of their careers;

– exploring associations between factors that may affect the retention of dental providers;

– determining current salaries.

	MATERIALS AND METHODS

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Survey instrument and implementation. We designed the survey instrument with input from the Health Resources and Services Administration (HRSA); HRSA regional dental consultants; dental directors from key community, migrant and homeless health centers; the primary investigator (K.B.); and other interested parties. After designing the questionnaire, we sent it to the 10 regional dental directors and other experienced CHC dental directors to test for validity and reliability. We eliminated redundant or ambiguous questions in this process. The institutional review board of the Texas A&M Health Science Center, Baylor College of Dentistry, Dallas, approved the questionnaire and survey process.

We obtained the addresses of all known CHC dentists from the 10 HRSA regional dental consultants or their counterparts. We then sent the survey to all dentists employed by CHCs that had dental components. The survey addressed general job satisfaction determinants and included questions about salaries and benefits. Finally, we asked dentists if they planned to remain in their CHC positions and, if not, how soon they planned to leave. In February and March 2002, we mailed a total of 569 surveys to dentists, including self-addressed postage-paid envelopes with each mailing.

Analysis. We entered the response data on spreadsheets and transferred them using a statistical software package (SPSS PC version 11, SPSS, Chicago). We then performed a frequency analysis for each question answered on the survey.

To measure associations between variables, we performed these statistical tests: contingency table analysis to obtain ² values and, when the assumptions for the ² test were not met, Fisher’s exact test. We used t tests to compare between-group means for continuous variables. We used bivariate logistic regressions on seven selected variables, with "intention to leave community health care dentistry" as the dependent variable. Variables were categorical with the exception of salary, which was a continuous variable. The seven independent variables used in this analysis were as follows:

– salary;

– position;

– years of dental practice;

– freedom to exercise professional judgment in the treatment of patients;

– pre-existing altruistic motivation;

– high value placed on loan repayment;

– amount of administrative time available for those dentists with administrative duties.

We placed variables that were statistically significant (P < .05) in each bivariate analysis into a multivariate logistic regression model to measure the extent of these associations. The only exception was administrative time, which did not apply to the entire group of dentists, but to a subset composed of dental directors.

	RESULTS

TOP ABSTRACT COMMUNITY HEALTH CENTER... MATERIALS AND METHODS RESULTS DISCUSSION STUDY LIMITATIONS CONCLUSIONS REFERENCES

 
Of the 569 surveys mailed to dentists, 420 were returned, for a response rate of 73.8 percent. The mean (± standard deviation) number of years worked in a CHC was 7.1 ± 6.9, with a median of 4.5 years. The majority of respondents (233 [56 percent] of 416) had 10 years or more of dental practice experience, 84 (20.2 percent) had between five and 10 years, 72 (17.3 percent) had between one and five years and 27 (6.5 percent) had less than one year of practice experience. Respondents’ single predominant role before employment in a CHC was "private practice associate or employee" (n = 137; 33.5 percent). Table 1 shows dentists’ responses to the question about previous occupational roles.

– felt a mission to the dentally underserved population (n = 304; 72.7 percent);

– wished to practice dentistry in a community-based setting (n = 278; 66.5 percent);

– attracted by the work schedules and leave policies of a CHC (n = 245; 58.6 percent). (The percentages total more than 100 owing to multiple possible responses.)

Perceptions of work environment. Dentists’ perceptions of the work environment generally were positive. Two hundred seventy-five (66.7 percent) of 412 respondents reported that their perception of the quality of the facility—including the building, equipment and supplies—was good or very good. Only eight respondents (< 2 percent) considered the quality to be poor. Three hundred eleven (76.2 percent) of 408 dentists reported that on-call weekend and evening duties occurred either seldom or never. Only 12 dentists (< 3 percent) responded that the on-call duties were excessive. The mean number of vacation days offered was 17.9 ± 5.9, with a median of 20 days; 312 (81.5 percent) of 383 respondents believed this to be an adequate amount of time.

Table 2 shows other indicators and perceptions that received a response of "adequate." Table 3 shows self-reported annual salaries in 2002 for staff dentists and dental directors.

We used an independent-samples t test to compare the reported salaries of staff dentists and dental directors who intended to leave community health dentistry with salaries of those who did not plan to leave. We used ² tests to measure the association between current position in the dental center (staff dentist or dental director) and intention to leave. Neither current position (staff dentist or dental director) nor salary was significantly associated with an intention to leave (P > .05). However, length of time of employment in CHC dentistry was significantly associated with an intention to leave. The 68.8 percent of respondents who indicated an intention to remain in CHC dentistry had a mean of 8.29 years of employment in a CHC setting, while the 31.2 percent of respondents who planned to leave had a mean of only 4.69 years of CHC employment (t test; P < .0001).

Years of experience. Bivariate logistic regression analysis verified the significance of the association between the intention to leave CHC dentistry and having less than one year of practice experience (OR = 10.2; P < .0001), having more than one year but less than five years of experience (OR = 6.9; P < .0001) and having more than five years but less than 10 years of experience (OR = 3.4; P < .0001), compared with dentists who had 10 years or more of experience.

We performed contingency table analyses on several factors that were suspected to affect job satisfaction in CHC dental clinics. These included perceptions of the

– degree of professional freedom in treating patients;

– restrictions involving the availability of specialty referral options;

– level of cooperation from CHC administration;

– level of cooperation from CHC boards of directors.

Freedom to exercise professional judgment. We used bivariate logistic regression analysis on the group as a whole; the results show that dentists who did not perceive themselves to be completely free to exercise their professional judgment in the treatment of their patients were twice as likely to indicate an intention to leave CHC dentistry as were those who believed they were completely free to exercise their judgment (OR = 2.0; P = .002).

The results of this study suggest that factors other than salary and benefits affect the retention of dentists in community health centers.

Altruistic motivation. Other studies have suggested that altruistic motivation is a significant factor in physicians’ and dentists’ decisions to continue to care for underserved populations.^7,8 In our survey, dentists who ranked "felt a mission to the dentally underserved population" as first in their top five reasons for choosing a practice opportunity with a CHC organization were significantly more likely to indicate that they were remaining in CHC dentistry, compared with dentists who did not rank that reason highly (P = .003). The significance of this association was present in the bivariate logistic regression analysis (OR = 2.1; P = .004).

Loan repayments. In sharp contrast, dentists who ranked an offer or promise of loan repayment as first or second in their top five reasons for choosing CHC dentistry were significantly more likely to indicate that they were leaving CHC dentistry than were dentists who did not rank loan repayment highly (²; P < .0001). Bivariate logistic regression analysis confirmed that dentists who ranked loan repayment highly in their reasons for choosing employment in a CHC setting were significantly more likely to indicate an intention to leave than were those who did not rank loan repayment highly (OR = 4.8; P < .0001).

Administrative time. We asked dental directors about their perceptions of the amount of time allowed them for administrative duties. "Administrative time" refers to time required to attend to nonclinical duties that are unique to the delivery of dental care within the CHC system. A ² test was significant in measuring the association between dental directors who planned to leave CHC dentistry and the perception of having an inadequate amount of administrative time (P = .002). Bivariate logistic regression analysis showed that dental directors who believed they did not have enough time to perform their administrative duties were significantly more likely to indicate an intention to leave CHC dentistry than were those who thought they had enough administrative time (OR = 2.97; P = .005).

Table 4 shows the results of the bivariate and multivariate logistic regression analyses using the variables associated significantly with an intention to leave CHC dentistry.

	DISCUSSION

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However, this study found that years of experience and length of service in a CHC setting were major determinants. These results may reflect the assumption that those who can adapt to the system of dental care delivery in a CHC setting are self-selecting for retention, while those who cannot adapt intend to leave. The data suggest that this decision is made in the first few years of CHC employment.

Responses to questions about other job satisfaction determinants are interesting, because the quality of the facility, numbers and quality of dental assistants and other day-to-day operating activities in CHC dental clinics did not appear to significantly affect the retention of personnel. In addition, the level of benefits, such as time off, continuing education allowances and insurance coverage, did not appear to affect retention to a significant degree.

However, freedom to exercise professional judgment was rated highly among dentists. In general, those dentists who perceived this freedom to be lacking were significantly more likely to indicate a desire to leave the CHC practice. In particular, the degree of availability of specialty referral options and the level of cooperation from the administration and the board of directors were significant factors dividing dentists who intended to stay from those who intended to leave. Clearly, improved communication is needed between dentists and their nondental administrators and boards of directors. This communication should address each group’s expectations and the ability to fulfill those expectations in a system with finite resources.

It is not surprising that we found that dentists who expressed an altruistic motivation to treat the underserved are more likely to stay in CHC practices, because other studies have shown similar results.^9,10 This finding should strengthen existing efforts to recruit future health care providers from the underserved and underrepresented communities to which they may return at some point in their careers.⁹ However, loan repayment may not be the best method for attracting and retaining health care providers in general—and dentists in particular—to underserved areas. This is underscored by our finding that dentists who ranked loan repayment highly as a reason for choosing employment in CHC dentistry were up to 4.8 times more likely to report an intention to leave the CHC setting than to stay.

One explanation could be that a dentist may have been promised loan repayment if he or she accepted a position at a particular CHC, but the repayment did not materialize. Although all CHCs are considered automatically to be in a federally designated Health Professional Shortage Area (HPSA), each center’s eligibility for loan repayment programs may change from one year to the next. This is due to chronic underfunding of loan repayment "slots" for HPSAs that do not score high enough in regard to need, and is a possible contributing factor to our finding of dentists’ intention to leave CHC dentistry.

Conversely, this finding may indicate that those who rated loan repayment highly and received the maximum benefit from it simply move on to other areas of interest. Once an educational loan has been repaid, the dentist’s effective total compensation is decreased.

	STUDY LIMITATIONS

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Although the response rate in our study was high (73.8 percent), the possibility of nonresponse bias exists, because funding was not available for follow-up surveys or telephone calls to nonrespondents. It is possible that the nonrespondents’ answers might have been materially different from those of the respondents.

In survey research, there always is a trade-off between the number of questions asked and the response rate. Although many other demographic questions about factors such as age, race and sex and other probing questions could have been included, we kept the questionnaire brief intentionally to encourage a high response rate.

In addition, this survey did not reach dentists who already had left the CHC system. Although we obtained much valuable information from existing dental providers in CHC practice, we cannot know the reasons why others have left.

	CONCLUSIONS

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It would be highly desirable to conduct biennial surveys to regularly monitor factors associated with retention and recruitment of dentists in community and migrant health center clinics. CHC administrators must be kept informed of the current conditions in the dental practice marketplace, know what other CHCs are budgeting for dentist positions, and receive candid feedback regarding relationships between dentists and health center administrators. Future studies could build in follow-up costs into the budget to pursue higher response rates via second mailings and follow-up telephone calls to nonrespondents.

Additional information could be obtained from dentists who leave CHC practice in the form of a standardized, anonymous exit survey, which could be delivered to regional HRSA consultants for review. This tactic might be especially useful for particular geographical areas or specific CHCs within regions that have high turnover rates for dental providers.

Dentists hired as dental directors should be given a clear description of the duties involved in the position, including any administrative requirements specific to a particular CHC. Clinicians recruited from private practice may be unfamiliar with such duties and may underestimate the amount of time needed to perform them. Similarly, executive directors of CHCs must allow sufficient time for administrative duties and alter their expectations of dental directors with regard to the number of patients who can be seen or the number of clinical procedures that they can perform.

Finally, people in charge of recruiting dentists must address the issue of loan repayment cautiously and honestly with new dentists, who highly value such a benefit. Students exiting dental schools with up to $100,000 in educational loans cannot realistically be expected to accept salaries below those of the private sector in the absence of loan repayment programs.