Abstract
Objectives
To investigate whether significant differences existed in the influence among factors considered during the selection process when ranking orthodontic programs and to understand how an individual’s race or ethnic background might affect what factors were more important than others.
Materials and Methods
A survey was distributed to orthodontic residents to assess overall preferences and differences in desirability of various factors between historically underrepresented racial and ethnic (HURE) and non-HURE applicants.
Results
A total of 115 individuals initiated the survey, and 98 were included for analysis. Sixteen respondents were considered HURE applicants. “Clear aligner therapy training,” “good quality of clinical faculty,” and “high number of cases started” had the highest mean desirability overall. The most important factors influencing program rank order were “satisfied current residents,” “low cost,” and “having multiple techniques and treatment philosophies taught.” HURE respondents rated “diversity of training of faculty” (P = .0154), “racial and ethnic diversity of current and former residents” (P = .0007), “racial and ethnic diversity of faculty” (P = .0002), “racial and ethnic diversity of patient population” (P = .0131), “male : female ratio of residents” (P = .0225), “participation in care of Medicaid patients” (P = .0251), and “dental school-based program” (P = .0493) higher than their non-HURE counterparts.
Conclusions
Clinical factors are the most important to program applicants. However, HURE applicants place greater importance than non-HURE applicants on characteristics that promote inclusivity and representation of individuals of similar racial and ethnic backgrounds (peers, mentors, and patients).
Keywords: Education, Residency, Applicant, Underrepresented, HURE
INTRODUCTION
Racial and ethnic representation among dental professionals is far from reflective of that of the United States population. The US Census reported that approximately 13.6% of the US population identified as Black or African American, and approximately 19.1% identified as Hispanic or Latino.1 However, only 3.8% of dentists identified as Black, and 5.2% identified as Hispanic.2 As graduation from an accredited dental institution is a requirement for continuing to specialty training, limited representation within dental schools naturally restricts that in specialty residencies. Authors of a recent study reported that, of all actively practicing dental specialists, 3.3% identified as African American or Black, and 2.5% identified as Hispanic.3
The need for increased representation in dentistry has been acknowledged, with many publications identifying areas for improvement within administration for recruitment and retention efforts to be effective. Commonly suggested solutions included using a more qualitative, holistic approach to admissions; reducing the cost of dental education; increasing racial and ethnic representation among dental faculty; and using dental pathway programs.4 However, authors of few studies specifically gave power to the perspectives of historically underrepresented racial and ethnic (HURE) students when exploring effective strategies to recruit and retain minoritized talent. In one of the few studies in which authors used this approach, it was determined that minoritized students were often influenced to pursue dentistry by their family dentist as well as dental school alumni who could offer mentorship.5 Participants also indicated that positive dental experiences and having a support system were factors that encouraged their own involvement in recruitment efforts locally.5 Others have shown that minoritized students, when appropriately supported by institutional infrastructure and commitment, found community solidarity and validation through their positionality and identity.6 These findings not only provide valuable insights into efforts that could be implemented to attract and support HURE students but also highlight how modifications to the dental school experience may have long-term benefits.
Similar factors may shape decisions when HURE students are selecting an orthodontic residency program; however, authors of no previous studies have examined associations between race or ethnicity and factors deemed most influential. Keith and Proffit7 found that orthodontic program reputation was the most important factor in determining individual preference for where to receive specialty training and that financial stress and family pressures were two primary areas of dissatisfaction. Lindauer et al.8 reported that the top factors considered by applicants for admissions ranking were satisfied current residents, multiple techniques taught, and good quality of clinical faculty. More recently, Nanney et al.9 identified resident satisfaction, positive interview experience, multiple techniques taught, number of patients treated, low cost, quality of clinical faculty, and modern clinical facilities and technologies as factors considered desirable. Conversely, less desirable factors included hospital-based programs, heavy emphasis on research time, certificate-only programs, and those that required considerable work after hours.9 It remains unclear whether these factors influence HURE applicants to the same degree, and it is possible that they may serve as motivating or discouraging elements when determining residency program ranks for orthodontic admission.
In 2020, the American Dental Association reported that 9.9% of all orthodontic residents were HURE students.10 This low percentage has been relatively stable over the last 30 years despite an uptick in HURE dentists over the same period. By understanding the factors that may make an orthodontic program more appealing to minoritized applicants, programs can identify methods to attract and retain HURE students and support increased representation within the specialty. The current study was designed to incorporate detailed demographic information not obtained in previous studies to elucidate the associations between applicant background and factors influencing ranking of orthodontic programs. The aim of this study was to determine the relative importance of various factors considered by HURE and non-HURE applicants when ranking orthodontic programs during the selection process. The null hypothesis was that no difference would appear in the factors considered between HURE and non-HURE applicants.
MATERIALS AND METHODS
This research study was considered exempt by the Virginia Commonwealth University Institutional Review Board under protocol HM20026619.
A survey to evaluate factors considered by applicants when ranking orthodontic programs was developed and included items similar to those featured in a previous study.8 The current study was updated to include advancements in the orthodontic field as well as factors that may disproportionately affect HURE applicant rankings, including “racial and ethnic diversity of current and former residents,” “racial and ethnic diversity of faculty,” and “perceived feelings of safety.” The survey consisted of four sections. After entering demographic information, respondents were presented with 41 factors that applicants might find advantageous or disadvantageous when ranking programs and were asked to rate the desirability of each from very desirable to very undesirable. They then indicated which factors they considered within the top five most important when ranking orthodontic programs. Lastly, respondents indicated and elaborated on any perceived barriers that they encountered during the application and interview process.
Business cards with QR codes to the electronic survey were made available to current orthodontic residents at the Graduate Orthodontic Residency Program (GORP) conference held in July 2023 in St. Louis. The GORP e-mail list was also obtained for electronic distribution of the survey to current orthodontic residents in the classes of 2023–2026 who consented to being contacted. To avoid obtaining duplicate responses, the survey asked participants if they had already completed the survey at the GORP conference.
Participation in the survey was voluntary. Respondents were also informed that they could stop completing the survey at any time.
Study data were collected and managed using the Research Electronic Data Capture (REDCap) tool hosted at Virginia Commonwealth University. REDCap is a secure application for delivering and recording survey responses for research while maintaining respondent anonymity and confidentiality.11
Responses were summarized using counts and percentages or averages and standard deviations. Associations between self-reported barriers and resident demographics were assessed using Fisher’s exact tests. Differences between factor rankings for HURE and non-HURE respondents were compared using nonparametric Wilcoxon tests. Significance level was set at 0.05. SAS EG v.8.2 (SAS Institute, Cary, NC) was used for all analyses.
RESULTS
The survey was distributed electronically to 288 current orthodontic residents. A total of 115 individuals initiated the survey, and 98 respondents completed the survey in its entirety. These 98 respondents were considered for analysis.
Demographics
Of the respondents, 58% were female, 60% White, and 93% non-Hispanic. A total of 16 respondents were considered HURE applicants (Black or African American, American Indian or Alaskan Native, Hispanic, or all of the above). More than one-third were married (37%), and 14% reported having at least one dependent. More than half reported student debt exceeding $100,000, with 15% over $400,000 and 33% reporting debt between $200,000 and $400,000. Complete demographics are provided in Table 1.
Table 1.
Self-Report Characteristics of Respondents
| No. (%) | |
|---|---|
| Sex | |
| Male | 41 (42%) |
| Female | 57 (58%) |
| Race | |
| Asian | 18 (19%) |
| Black or African American | 8 (8%) |
| Middle Eastern | 6 (6%) |
| White | 58 (60%) |
| Other or multiracial | 6 (6%) |
| Ethnicity | |
| Hispanic | 7 (7%) |
| Non-Hispanic | 90 (93%) |
| Marital status | |
| Married | 36 (37%) |
| Single | 62 (63%) |
| Dependents | |
| Yes | 13 (14%) |
| No | 79 (86%) |
| Debt | |
| Up to 100K | 37 (38%) |
| > 100K | 61 (62%) |
| <50K | 29 (30%) |
| 50–100K | 8 (8%) |
| 100–200K | 14 (14%) |
| 200–400K | 32 (33%) |
| >400K | 15 (15%) |
Factors
Factors were coded on a 5-point Likert scale ranging from 2 (very desirable) to −2 (very undesirable). Of the 41 factors rated by respondents, “clear aligner therapy training” had the highest rating with an average score of 1.8. Other factors with high desirability included “good quality of clinical faculty” and “high number of cases started” with an average of 1.7 and 1.6, respectively. The least desirable factor was “heavy emphasis on research time” with an average of −0.6, and 57% of respondents rated this item undesirable or very undesirable. Other factors that were not rated as desirable on average by respondents included “nondental school-based and nonhospital-based” with an average of −0.4, “class size 6+” with an average of −0.4, and “certificate only offered” with an average of −0.3. A complete summary of the ratings is provided in Table 2 and Figure 1.
Table 2.
Summary of Ratings for Orthodontic Program Featuresa
| Mean ± SD | D | N | ND | |
|---|---|---|---|---|
| Clear aligner therapy training | 1.8 ± 0.48 | 98% | 2% | 0% |
| Good quality of clinical faculty | 1.7 ± 0.51 | 99% | 2% | 0% |
| High number of cases started | 1.6 ± 0.56 | 96% | 4% | 0% |
| Satisfied current residents | 1.6 ± 0.67 | 96% | 2% | 2% |
| Low cost (tuition and expenses) | 1.6 ± 0.83 | 91% | 6% | 4% |
| Good impression of current residents at interview | 1.6 ± 0.60 | 95% | 6% | 0% |
| Good impression of faculty at interview | 1.6 ± 0.57 | 96% | 4% | 0% |
| Multiple technique(s) or treatment philosophies taught | 1.5 ± 0.57 | 96% | 4% | 0% |
| Financial support available | 1.5 ± 0.85 | 88% | 9% | 4% |
| Use of new technology in the clinic | 1.5 ± 0.63 | 95% | 5% | 1% |
| Heavy emphasis on clinic time | 1.5 ± 0.62 | 94% | 6% | 0% |
| Surgical orthodontic experience | 1.5 ± 0.74 | 93% | 6% | 2% |
| High participation of clinical faculty | 1.4 ± 0.63 | 94% | 5% | 1% |
| Good location (hometown, inexpensive, fun) | 1.4 ± 0.72 | 89% | 11% | 1% |
| Good program reputation | 1.3 ± 0.75 | 89% | 11% | 0% |
| Perceived safety of location | 1.3 ± 0.77 | 87% | 11% | 3% |
| Positive spouse, family, or peer support | 1.2 ± 0.79 | 79% | 19% | 1% |
| Participation in care of cleft or craniofacial patients | 1.2 ± 0.81 | 85% | 12% | 4% |
| Lab fabricates appliances (vs. resident) | 1.0 ± 0.97 | 71% | 21% | 8% |
| Diversity of training of faculty | 1.0 ± 0.82 | 67% | 33% | 1% |
| High number of full-time faculty | 0.9 ± 0.85 | 70% | 26% | 5% |
| Extensive interdisciplinary care training | 0.9 ± 0.80 | 75% | 21% | 5% |
| Program length < 30 mo | 0.9 ± 1.13 | 65% | 22% | 13% |
| High number of assistants or auxiliary staff | 0.8 ± 0.83 | 63% | 35% | 3% |
| Racial and ethnic diversity of patient population | 0.8 ± 0.75 | 60% | 41% | 0% |
| Master’s degree offered or required | 0.8 ± 1.05 | 62% | 29% | 9% |
| Racial and ethnic diversity of current and former residents | 0.7 ± 0.82 | 54% | 44% | 2% |
| Dental school-based program | 0.7 ± 0.92 | 60% | 34% | 6% |
| Longevity or tenure of faculty | 0.7 ± 0.81 | 53% | 45% | 3% |
| Class size < 6 | 0.7 ± 1.06 | 54% | 38% | 9% |
| Racial and ethnic diversity of faculty | 0.6 ± 0.80 | 50% | 49% | 2% |
| Participation in care of Medicaid patients | 0.5 ± 1.01 | 49% | 40% | 12% |
| Male : Female ratio of residents | 0.5 ± 0.73 | 38% | 62% | 1% |
| Male : Female ratio of faculty | 0.4 ± 0.71 | 38% | 59% | 3% |
| Heavy emphasis on class time or didactics | 0.3 ± 0.89 | 40% | 43% | 18% |
| Program length 30 + mo | −0.2 ± 1.20 | 27% | 33% | 41% |
| Certificate only offered | −0.3 ± 1.05 | 19% | 40% | 41% |
| Hospital-based program | −0.3 ± 0.97 | 15% | 41% | 44% |
| Class size 6+ | −0.4 ± 1.07 | 16% | 42% | 43% |
| Nondental school-based and nonhospital-based | −0.4 ± 1.02 | 10% | 51% | 39% |
| Heavy emphasis on research time | −0.6 ± 1.05 | 13% | 29% | 57% |
D indicates desirable or very desirable; N, neutral; and ND, undesirable or very undesirable.
Figure 1.
Summary of ratings for orthodontic program characteristics.
HURE Respondents vs. Non-HURE Respondents
Statistically significant differences were found between HURE and non-HURE respondents when considering the relative desirability of factors influencing applicant ranking of orthodontic programs (Table 3, Figure 2). HURE respondents rated “diversity of training of faculty” (P = .0154), “racial and ethnic diversity of current and former residents” (P = .0007), “racial and ethnic diversity of faculty” (P = .0002), “racial and ethnic diversity of patient population” (P = .0131), “male : female ratio of residents” (P = .0225), “participation in care of Medicaid patients” (P = .0251), and “dental school-based program” (P = .0493) higher than their non-HURE counterparts. On the other hand, non-HURE respondents rated shorter program lengths (<30 months favorably, P = .0338; ≥30 months unfavorably, P = .0240) and “positive spouse, family, or peer support” (P = .0256) significantly more favorably than their HURE counterparts. The most notable differences were observed when comparing sentiment toward the racial and ethnic representation of current and former residents which had a median rating of 2 (strongly agree) from HURE respondents (interquartile range [IQR] low, high: 1, 2) compared with a median of 0 (neutral; IQR: 0, 1) for non-HURE respondents, and racial and ethnic representation of faculty, which had a median rating of 1.5 (strongly agree or agree; IQR: 1, 2) among HURE respondents compared with 0 (neutral; IQR: 0, 1) for non-HURE respondents.
Table 3.
Comparison of Ratings [Median, (IQR [low, high])] between HURE and Non-HURE Respondents
| Factor | HURE (n = 16) | Non-HURE (n = 81) | P Valuea |
|---|---|---|---|
| Satisfied current residents (i.e., program culture, level of education) | 2 (2, 2) | 2 (1, 2) | .2836 |
| Multiple technique(s) or treatment philosophies taught | 2 (1, 2) | 2 (1, 2) | .1564 |
| Good program reputation | 1.5 (1, 2) | 1 (1, 2) | .3720 |
| Good quality of clinical faculty | 2 (1, 2) | 2 (1, 2) | .2502 |
| High number of full-time faculty | 1 (0, 1) | 1 (0, 1) | .5935 |
| High participation of clinical faculty | 1 (1, 2) | 1 (1, 2) | .2415 |
| Longevity or tenure of faculty | 0 (0, 1) | 1 (0, 1) | .6388 |
| Diversity of training of faculty | 1.5 (1, 2) | 1 (0, 1) | .0154 |
| High number of assistants or auxiliary staff | 1 (0, 2) | 1 (0, 1) | .8326 |
| Lab fabricates appliances (vs. resident) | 2 (1, 2) | 1 (0, 2) | .0879 |
| Heavy emphasis on clinic time | 2 (1, 2) | 2 (1, 2) | .8493 |
| Heavy emphasis on class time or didactics | 0 (0, 1) | 0 (0, 1) | .4613 |
| Heavy emphasis on research time | −1 (−1, 0) | −1 (−2, 0) | .5278 |
| Class size < 6 | 0.5 (0, 1) | 1 (0, 2) | .2822 |
| Class size 6+ | 0 (−1, 0) | 0 (−1, 0) | .3151 |
| Racial and ethnic diversity of current and former residents | 2 (1, 2) | 0 (0, 1) | .0007 |
| Racial and ethnic diversity of faculty | 1.5 (1, 2) | 0 (0, 1) | .0002 |
| Racial and ethnic diversity of patient population | 1 (1, 2) | 1 (0, 1) | .0131 |
| Male : Female ratio of residents | 1 (0, 2) | 0 (0, 1) | .0225 |
| Male : Female ratio of faculty | 0.5 (0, 1) | 0 (0, 1) | .1157 |
| Master’s degree offered or required in addition to orthodontic certificate | 1 (0, 1.5) | 1 (0, 1.5) | .9918 |
| Certificate only offered | 0 (−1, 0) | 0 (−1, 0) | .6629 |
| Dental school-based program | 1 (1, 1.5) | 1 (0, 1) | .0493 |
| Hospital-based program | 0 (−1, 0) | 0 (−1, 0) | .8885 |
| Nondental school-based and nonhospital-based program | 0 (−1.5, 0) | 0 (−1, 0) | .4118 |
| Program length < 30 mo | 0 (0, 1) | 1 (0, 2) | .0338 |
| Program length 30 + mo | 0 (0, 1) | 0 (−1, 0) | .024 |
| Low cost (tuition and expenses) | 2 (1, 2) | 2 (2, 2) | .8855 |
| Financial support available (i.e., stipend, salary, scholarship) | 2 (1.5, 2) | 2 (2, 2) | >.999 |
| High number of cases started | 2 (1, 2) | 2 (1, 2) | .7154 |
| Participation in care of cleft or craniofacial patients | 1 (1, 2) | 1 (1, 2) | .4975 |
| Participation in care of Medicaid patients | 1 (0, 2) | 0 (0, 1) | .0187 |
| Extensive interdisciplinary care training | 1 (1, 1.5) | 1 (0, 1) | .3128 |
| Use of new technology in the clinic | 2 (1, 2) | 2 (1, 2) | .9425 |
| Clear aligner therapy training | 2 (2, 2) | 2 (1.5, 2) | .2752 |
| Surgical orthodontic experience | 2, (1, 2) | 2, (1, 2) | .8420 |
| Good location (hometown, inexpensive, fun) | 1, (0.5, 2) | 2, (1, 2) | .0974 |
| Perceived safety of location | 1, (0, 2) | 1, (1, 2) | .0616 |
| Positive spouse, family, or peer support | 1, (0, 1) | 1, (1, 2) | .0256 |
| Good impression of current residents at interview | 2, (1.5, 2) | 2, (1, 2) | .3541 |
| Good impression of faculty at interview | 2, (1, 2) | 2, (1, 2) | .5066 |
P value from nonparametric Wilcoxon tests due to small sample size among HURE respondents. Rating scale: 2 = very desirable, 1 = desirable, 0 = neutral, −1 = undesirable, −2 = very undesirable.
Figure 2.
Summary of characteristics rated significantly differently between HURE and non-HURE respondents.
Top Five Most Important Factors
Respondents were asked to identify up to five factors they deemed most important for ranking the desirability of an orthodontic program during the application process. “Satisfied current residents” was selected by 55% of residents as one of their top five most important factors, with 19% of respondents indicating it was their most important factor and 13% of respondents indicating it as second most important. “Low tuition” (50%) and “having multiple techniques and treatment philosophies taught” (50%) were also selected frequently. A complete summary of the ratings is provided in Table 4.
Table 4.
Summary of Top Five Factors Selected by Respondents
| 1 | 2 | 3 | 4 | 5 | Ranked in Top 5 | |
|---|---|---|---|---|---|---|
| Satisfied current residents | 19% | 13% | 8% | 6% | 8% | 55% |
| Low cost | 13% | 13% | 11% | 7% | 5% | 50% |
| Multiple technique(s) or treatment philosophies taught | 11% | 14% | 9% | 7% | 8% | 50% |
| Heavy emphasis on clinic time | 10% | 8% | 10% | 6% | 7% | 42% |
| Good location (hometown, inexpensive, fun) | 9% | 3% | 8% | 3% | 10% | 34% |
| Program length < 30 mo | 8% | 8% | 5% | 2% | 1% | 24% |
| Good program reputation | 7% | 10% | 5% | 7% | 2% | 32% |
| High number of cases started | 6% | 5% | 11% | 7% | 5% | 35% |
| Positive spouse, family, or peer support | 4% | 1% | 2% | 3% | 3% | 13% |
| Good quality of clinical faculty | 3% | 6% | 9% | 9% | 2% | 30% |
| Financial support available | 3% | 5% | 3% | 2% | 4% | 17% |
| Good impression of current residents at interview | 3% | 0% | 1% | 4% | 6% | 14% |
| Participation in care of cleft or craniofacial patients | 2% | 2% | 0% | 1% | 1% | 6% |
| Use of new technology in the clinic (3D printing, digital scanning, in-house aligners, CBCT, etc.) | 1% | 1% | 2% | 7% | 11% | 22% |
| Good impression of faculty at interview | 0% | 2% | 0% | 2% | 3% | 7% |
| Clear aligner therapy training | 0% | 1% | 2% | 3% | 5% | 11% |
| Class size < 6 | 0% | 1% | 1% | 4% | 2% | 8% |
| Extensive interdisciplinary care training | 0% | 1% | 0% | 4% | 1% | 6% |
| Heavy emphasis on class time or didactics | 0% | 1% | 0% | 0% | 1% | 2% |
| Racial and ethnic diversity of current and former residents | 0% | 0% | 3% | 2% | 1% | 6% |
| Lab fabricates appliances (vs. resident) | 0% | 0% | 2% | 0% | 1% | 3% |
| High number of full-time faculty | 0% | 0% | 2% | 0% | 0% | 2% |
| Diversity of training of faculty | 0% | 0% | 1% | 0% | 1% | 2% |
| Longevity or tenure of faculty | 0% | 0% | 1% | 0% | 1% | 2% |
| High participation of clinical faculty | 0% | 0% | 0% | 8% | 2% | 10% |
| High number of assistants or auxiliary staff | 0% | 0% | 0% | 1% | 1% | 2% |
| Perceived safety of location | 0% | 0% | 0% | 1% | 0% | 1% |
| Racial and ethnic diversity of faculty | 0% | 0% | 0% | 1% | 0% | 1% |
| Dental school-based program | 0% | 0% | 0% | 0% | 1% | 1% |
| Surgical orthodontic experience | 0% | 0% | 0% | 0% | 0% | 0% |
| Racial and ethnic diversity of patient population | 0% | 0% | 0% | 0% | 0% | 0% |
| Master’s degree offered or required in addition to orthodontic certificate | 0% | 0% | 0% | 0% | 0% | 0% |
| Participation in care of Medicaid patients | 0% | 0% | 0% | 0% | 0% | 0% |
| Male : Female ratio of residents | 0% | 0% | 0% | 0% | 0% | 0% |
| Male : Female ratio of faculty | 0% | 0% | 0% | 0% | 0% | 0% |
| Program length 30 + mo | 0% | 0% | 0% | 0% | 0% | 0% |
| Certificate only offered (no master’s degree) | 0% | 0% | 0% | 0% | 0% | 0% |
| Hospital-based program | 0% | 0% | 0% | 0% | 0% | 0% |
| Class size 6+ | 0% | 0% | 0% | 0% | 0% | 0% |
| Nondental school-based and nonhospital-based program | 0% | 0% | 0% | 0% | 0% | 0% |
| Heavy emphasis on research time | 0% | 0% | 0% | 0% | 0% | 0% |
Barriers
Twelve of the 98 participants (12%) reported experiencing a perceived barrier during the application process for orthodontic residency. Of those, nine provided further description of the barrier (Table 5). The descriptions included student race (n = 3), marital status or sexuality (n = 3), financial (n = 1), military requirements (n = 1), and COVID-related (n = 1) comments. Applicant characteristics associated with reporting a perceived barrier included race (P = .0137), ethnicity (P = .0398), and debt level (P = .0267). Complete results are provided in Table 6. Although the number of respondents in certain racial categories was small, a higher proportion of those who identified as Black (50%) or other or multiracial (20%) reported experiencing perceived barriers compared to those who identified as White, Indian, or Asian (12%, 0%, and 0%, respectively). Those who identified as Hispanic also reported experiencing a barrier at a significantly higher rate than non-Hispanic respondents (43% vs. 20%). Those with more than $100,000 in student debt were significantly more likely to report experiencing a barrier than those with less debt (18% vs. 3%).
Table 5.
Perceived Barriers Identified by Respondents
| Description of Barrier | Categorya |
|---|---|
| COVID-19 all interviews were over Zoom/virtual | COVID |
| There is a stigma related to the hair of Black people, especially as it pertains to cultural styles and significance. Standards of professionalism that are founded and based in white supremacy take precedent over the diversification and education on these matters | Race |
| I was asked questions about my marital status and political views | Family |
| Race or gender | Race or gender |
| Some faculty expressed concerns over military commitments | Military |
| African American woman | Race |
| As a gay applicant, I maintained neutral language when referring to my husband (i.e., referred to him as my “spouse”), as I didn’t want my sexuality to be used against me. | Sexuality |
| Once when talking about wanting to start a family at one point. | Family |
| Could go on and on about how dentistry and orthodontics are inherently gate-kept professions. The amount of money it cost just to apply to ortho is absurd. Coupled with all the additional costs from the application/interview season. The amount of hurdles I had to climb in order to apply to a select number of schools was pretty daunting throughout the entire process. Luckily for me, it worked out, but for a lot of people, it simply does not. | Financial |
Categories assigned after reading descriptions.
Table 6.
Associations Between Reporting a Perceived Barrier (Yes or No) and Respondent Characteristics
| Yes, No. (%) | No, No. (%) | P Valuea | |
|---|---|---|---|
| Total sample | 12 (12%) | 86 (88%) | |
| Sex | >.999 | ||
| Female | 7 (12%) | 50 (88%) | |
| Race | .0137 | ||
| Asian | 0 (0%) | 18 (100%) | |
| Black or African American | 4 (50%) | 4 (50%) | |
| Middle Eastern | 0 (0%) | 6 (100%) | |
| Other or multiracial | 1 (20%) | 4 (80%) | |
| Hispanic | 3 (43%) | 4 (57%) | |
| Non-Hispanic | 9 (10%) | 81 (90%) | |
| Marital status | .3522 | ||
| Married | 6 (17%) | 30 (83%) | |
| Single | 6 (10%) | 55 (90%) | |
| Dependents | .6795 | ||
| Yes | 2 (15%) | 11 (85%) | |
| No | 10 (13%) | 68 (87%) | |
| Debt | .0267 | ||
| Up to 100K | 1 (3%) | 36 (97%) | |
| >100K | 11 (18%) | 49 (82%) | |
| Debt | .0123 | ||
| <50K | 0 (0%) | 29 (100%) | |
| 50–100K | 1 (13%) | 7 (88%) | |
| 100–200K | 5 (36%) | 9 (64%) | |
| 200–400K | 4 (13%) | 27 (87%) | |
| >400K | 2 (13%) | 13 (87%) |
P value from Fisher’s exact test.
DISCUSSION
When considering factors for ranking orthodontic programs, respondents ranked “clear aligner therapy training” as the most desirable. Authors of similar studies did not include this factor as a survey item for direct comparison. As an increasing number of adults pursue orthodontic treatment, clear aligners have become a popular treatment option. To meet the needs of an evolving patient population, experience performing clear aligner therapy should be offered at orthodontic residency programs. Other factors that were considered highly desirable were “good quality of clinical faculty” and “high number of cases started.” This was consistent with previous studies, emphasizing that the quality of clinical education and experience remain high priorities for individuals seeking orthodontic training.8,9 The least desirable factor identified by respondents was “heavy emphasis on research time,” which was consistent with previous studies.8,12
Although factors rated most and least desirable were similar among different demographic groups, HURE respondents found some factors more desirable than their non-HURE counterparts. HURE respondents found “racial and ethnic diversity of current or former residents” and “racial and ethnic diversity of faculty” more desirable than non-HURE respondents. At the predoctoral level, increasing the racial and ethnic representation of the clinical faculty has been a proven method for increasing recruitment and retention of HURE students;13 therefore, similar efforts at a postdoctoral level would be beneficial for increasing representation within dental specialties. A history of diverse representation among resident classes may be considered by applicants as reflective of the relative importance that a program places on inclusivity efforts. Having diverse alumni also cultivates more opportunities for mentorship, and role models are often a strong influence on education and career aspirations.14 The importance of mentorship cannot be overstated. Particularly among HURE students, residents, and faculty, mentorship can be an important motivator in dentistry when trust, empathy, and acknowledgement of racial identity, nuance, and other factors are observed.15 HURE respondents also found “racial and ethnic diversity of patient population” and “participation in care of Medicaid patients” more desirable than non-HURE respondents. These results were consistent with the findings of Mertz et al.,16 who reported that a majority of HURE dentists in practice found the opportunity to serve vulnerable and low-income communities and serving their own racial or ethnic group as important factors in determining job satisfaction.
Several HURE respondents reported barriers during the application and interview process. Some reported concerns about how they presented themselves to ensure their presentation was not counted against them during interviews. For example, one respondent reported maintaining “neutral language” when discussing relationships and family planning to ensure that these topics did not detract from their qualifications. It was also noted that, historically, stigma correlating different hairstyles and coarser textures with lack of professionalism has existed, discouraging diverse applicants from presenting authentically.17 These issues align with those of scholars calling for a reimagined professionalism inclusive of well-being and wellness and moving away from appearance preference and acclimation at best to actual discriminatory practices at worst.18 Scholars have also recognized a need for more inclusive health care practices, expanding long-held notions regarding beneficence and maleficence beyond simply doing good and refraining from harm to including intentionality to benefit patients, promoting their welfare, and removing conditions that cause harm.19 A more diverse, empathetic orthodontic workforce may be more willing to participate and immerse themselves in these endeavors.
Lastly, high tuition and expenses were perceived as barriers. Authors of a recent study suggested that cost has become a significant factor guiding program selection and rank, with low-cost programs considered more desirable.9 Additionally, applicants who carry higher debt placed greater emphasis on the cost of residency when selecting and ranking residency programs than those with little or no debt.9 Cost may also impact diversification of the specialty, as it has been identified as a primary deterrent for HURE students pursuing dental school.20 Although many scholarship and loan repayment programs such as the National Health Service Corps (NHSC) are geared toward HURE students, NHSC scholarship recipients must commit to completing their training in primary care, which is limited to general dentistry, advanced education in general dentistry, pediatric dentistry, and public health dentistry.21 Poole et al.22 found that participation in NHSC was significantly associated with lower odds of specialization. Therefore, they suggested it may be advantageous for NHSC and similar programs to encompass specialty education to encourage diversification of the various dental specialties and address the gaps in dental specialty access in underserved communities.22
Limitations
A limitation of this study was that the survey was only distributed to current orthodontic residents, which may have introduced recall bias. Responses may have also been influenced by current residency experiences, as residents may have prioritized factors that contributed to an improved residency experience rather than those that influenced their initial ranking decisions. It is also possible that the perceived barriers expressed in this survey were an underestimation because, in the study, we only captured individuals that successfully navigated the application and interview process to match into the orthodontic specialty. Authors of future studies could aim at distributing the survey to orthodontic applicants earlier in the cycle.
The response rate of 34.0% was lower than the 46.9% response rate in the Lindauer et al.8 study but similar to the 27.3% response rate in the Nanney et al.9 study. The response rate may have been impacted by overall survey length, as 16 individuals who initiated the survey did not reach the item asking which factor they ranked as most important. However, in this study, we still offer valuable insights regarding how race and ethnic background may influence the difference in desirability of orthodontic program variables. Specifically looking at the HURE groups, 8% of individuals in this study identified as Black or African American, and 7% identified as Hispanic. These groups were well represented in this study, as only 4% and 7% of all individuals enrolled in orthodontic programs in 2023 identified as Black or African American or Hispanic, respectively.23
CONCLUSIONS
HURE students found “racial and ethnic diversity of current or former residents,” “racial and ethnic diversity of faculty,” “racial and ethnic diversity of patient population,” “male : female ratio of current residents,” and “participation in care of Medicaid patients” as more desirable characteristics of orthodontic programs during the application process than did non-HURE students, who were more neutral regarding these factors.
The top factors overall when comparing potential orthodontic program choices were “clear aligner therapy training,” “good quality of clinical faculty,” and “high number of cases started.”
The most important factors influencing program rank order were “satisfied current residents,” “low cost,” and “having multiple techniques and treatment philosophies taught.”
Perceived barriers to the application and interview process included race or ethnicity, sexuality, and cost. These disproportionately affected the application and interview experience of HURE students.
ACKNOWLEDGMENTS
This study was supported in part by a grant from the Southern Association of Orthodontists and by the Virginia Orthodontic Education and Research Foundation.
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