Army Dental Officer Retention

INTRODUCTION

The U.S. Army has had difficulty recruiting and retaining dentists, because of declining dental school enrollment, a robust economic environment for dentistry, changes in demographic features of dental providers, and the current operational tempo of the military. Identifying factors associated with recruitment and retention of Army Dental Corps officers is paramount when the changes in the dental profession are taken into account.

Change in the dental profession is evident in trends in U.S. dental school enrollment. Dental school enrollment peaked at 6,301 students in 1975 but leveled off at 4,688 students in 2005.1 In 2005, 44% of first-year dental students (n = 2,078) were women, representing a sharp increase from 1980, when 17% of the students were women.1 Minority student enrollment in dental schools increased from 13% in 1980 to 34% in 2005.1 Asian students represent the greatest growth in the minority dental student population. Although changes in the demographic characteristics of dental students may result in a dental profession that more closely mirrors the U.S. population, the effect on the military is unknown. Traditionally, the Army has not been as successful in recruiting and retaining female and minority dentists at the same rates as Caucasian male dentists.

At the same time that dental school demographic features are changing, civilian dental practice is experiencing an economic boom. The average net income of a full-time solo dental practitioner increased 1 10% from 1990 to 2003. The average net income of general practitioners was $180,650 and that of specialty practitioners was $287,190 in 2003.2 The robust civilian dental economic environment stresses the ability of the military to retain dental providers when military pay is significantly less at the early stages of a dental officer's career.

In the past 10 years, military recruitment problems have been addressed with a multiple-year, dental school scholarship program, called the Health Professional Scholarship Program (HPSP), and accession bonuses. The Army currently offers >130 HPSP scholarships per year, and historically applicants outpaced availability. These programs have improved the recruitment of dental officers in the past 3 years and are projected to continue to provide young dental officers in the future. However, the prolonged war in Southwest Asia seems to have decreased interest in the HPSP scholarships, and the Army has not filled its quota for the past 2 years. At the same time, retention of Dental Corps officers has decreased. A shortage of military dentists degrades the dental health of U.S. Army soldiers, which directly affects the deployability of the force.

Dental school expenses place a burden on dentists once they graduate. A 2004 study found that the majority of junior Army dental officers have significant student loans, even those who received HPSP scholarships.3 New military dental officers had student loan debt of $56,000. Accordingly, a large proportion of junior officers indicated that loan repayment or other monetary inducements would be major drivers for remaining on active duty. A student loan repayment program, called the Health Professions Loan Repayment Program, was initiated by the Dental Corps with moderate success.

Army dentistry has not been the only military service to experience difficulty with recruiting and retaining dental officers. In 2006, Stacey4 reported that the U.S. Navy experienced steady annual losses of Dental Corps officers, despite aggressive efforts to improve recruitment and retention. Recruiting woes forced the Navy Dental Corps to place more emphasis on programs such as the HPSP, the Financial Assistance Program, and an accession bonus for students to take a HPSP scholarship. Similarly, the Air Force has experienced recruiting shortfalls for Dental Corps officers for the past decade. The goal of the Air Force is to recruit ~150 accessions each year, but it has only averaged 120. Retention of these new Air Force dentists has been difficult as well; only 35% have remained on active duty after their initial service commitment.5 The purpose of this article was to identify the major factors associated with retention of Army Dental Corps officers in two recent retention surveys, i.e., the 2006 Junior Dental Corps Officer Retention Survey and the 2007 Senior Dental Corps Officer Retention Survey.

METHODS

Data Collection for the 2006 Junior Officer Survey

We modified a 2004 Army Dental Corps Retention Survey. The 2004 survey had been validated through previous use, but question addition and modification were necessary for each of the two surveys. The survey was pilot-tested with senior leaders and limited junior officers. Junior officer suggestions were used to change the questionnaire and to include a section on local and clinic leadership. Demographic information was limited to preserve anonymity, in hopes of increasing response rates. The Total Officer Personnel Management Information System was used to identify dental officers for inclusion in the survey. The Total Officer Personnel Management Information System had 588 e-mail addresses available for the 589 officers with the rank of captain or major who were on active duty as of September 18, 2006. The survey and request for completion were e-mailed on September 19, 2006, to the 588 identified officers, with 13 returned with invalid e-mail addresses and another 133 with unknown delivery status. A second e-mail attempt for those 146 officers on September 21, 2006, resulted in 14 undeliverable messages. The total sample size was 588, but only 574 officers were confirmed to have received the e-mail.

Data Collection for the 2007 Senior Officer Survey

We modified the 2006 Junior Officer Retention Survey by adding questions on the effect of 6- and 15 -month deployments. Questions on the importance of multiple special pays for retention were also added to the survey instrument. The survey was pilot-tested with senior leaders, and editorial changes were made to the instrument. The Total Officer Personnel Management Information System identified 346 lieutenant colonels and colonels, witii their e-mail addresses, to be included in the sample. The survey and request for completion were e-mailed on August 1, 2007, to the 346 identified officers, and a reminder was sent in the middle of September. The commander of the U.S. Army Dental Command sent an additional e-mail to all dentists, requesting participation in the survey, which might have increased the response rate for the senior officer survey.

Questionnaire

The first section of the questionnaire assessed officers' attitudes toward retention, pay, and the importance of various factors for retention. The likelihood of retiring from active duty when eligible was scored on a 7-point Likert scale, and officers were asked to rank-order the following items with respect to their importance for being retained on active duty: retirement benefits, continuing education, duty location of choice, increase in dental bonuses, improved quality of practice, command and staff opportunities, and specialty training. The respondents answered two open-ended questions and were asked to provide comments on the top reasons for remaining in the Dental Corps and to list one thing that the Army Dental Care System could do to keep them in the military. The second section of the survey attempted to identify the effect of leadership on retention. Questions were asked to determine satisfaction with Dental Corps senior leadership and local leadership. The last section aimed at gathering limited demographic information on the respondents.

Data Analysis

As the surveys were received, the answers for all questions were coded numerically for ease of analysis and were entered into an Excel spreadsheet (Microsoft, Redmond, Washington). The spreadsheet was then imported into SPSS 10.1 for Windows (SPSS, Chicago, Illinois) for analysis. Descriptive statistics were the basis for this analysis.

RESULTS

In the 2006 survey, a total of 245 surveys were returned, for an overall response rate of 42%. There was no practical difference in the rank of responders, inasmuch as 40% of captains and 42% of majors responded to the survey. There was a difference in gender, inasmuch as 39% of male officers and 49% of female officers responded to the Junior Officer Retention Survey. Total responses for the 2007 Senior Officer Retention Survey were 262 of 346, for an overall response rate of 76%. There were differences in response rates according to rank and gender, inasmuch as 67% of lieutenant colonels (101 of 150 lieutenant colonels) and 80% of colonels (156 of 196 colonels) responded to the survey. Five individuals did not identify their rank. Seventy-one percent of men (221 of 310 officers) and 58% of women (21 of 36 officers) responded to the survey, with 9 individuals not identifying gender.

The likelihood of remaining on active duty until retirement and how many years the officers intend to stay on active duty are two determinants of long-term retention of dental officers. Table I shows the responses regarding the likelihood of staying on active duty. More than one-half of junior officers (127 of 237 junior officers) responded as being highly unlikely or unlikely to remain on active duty. Only 16% of junior officers stated that they were likely or very likely to remain until retirement. The majority of senior officers (75% of lieutenant colonels and 91% of colonels) were likely or very likely to remain in the Army until retirement. The large proportion of senior officers intending to stay is an expected finding, but the small proportion of junior officers intending to make a career is alarmingly low. There seemed to be minimal differences in the intention to stay on active duty according to gender, as shown in Table I. Respondents were also asked to estimate the number of years they would serve on active duty. Only 19% of junior officers thought they would serve ^H years, and only 12% thought they would serve &20 years. The mean length of the expected career in the Army for senior officers was 24.25 years, but this number is skewed because there were officers responding who had already exceeded the minimal number of years qualifying them for retirement.

The results indicated that pay is a major driver for retention, but pay is even more important to junior officers. Seventy-two percent of junior officers cited increases in bonuses as the first or second most important item to keep them on active duty. Similarly, 79% responded that current pay levels are a key driver in their plans to leave the military. Sixty-nine percent of junior officers stated that a bonus of $30,000 to $40,000 per year would be influential in changing their decision to leave the Army.

Dental specialty training was found to be an important factor in both recruitment and retention of junior officers. Sixty-two percent of nonspecialists cited specialty training as an important factor in their decision to stay on active duty. Seventy-four percent of all junior officers rated specialty training as important to retention, whereas only 24% of respondents cited no interest in specialty training. The HPSP is the most important recruitment tool for the Dental Corps, as evidenced by 85% of junior officers citing the scholarships as the most important factor in joining the Dental Corps. The possibility of dental school loan repayment was ranked as the second most important reason for entering the Dental Corps, cited by 62% of respondents.

Senior officers were asked to list the top two reasons for remaining in the Dental Corps. The top five responses were quality of clinical practice/life, retirement benefits, duty location, pay, and patriotism. When they were asked a similar question on what would keep them in the military, duty location, increases in pay, increased quality of practice, and decreased deployment time were the most often cited responses. Although pay was still a concern among senior officers, it was much less demonstrable, compared with the junior officers; 79% of junior officers cited pay as the motivating factor for leaving the Army. Only 35% of senior officers cited the need for increased pay as the primary retention factor. Junior officers provided many comments about comparable pay between dentists and family practice physicians in the civilian sector.

Officers were asked whether senior and local leaders were aware of their issues and were taking action on those issues. All respondents felt that both senior and local leaders were aware of the issues (75% for junior officers and 91% for senior officers), but only 41% of junior officers felt that action was being taken to address the issues, compared with 75% of senior officers. The results for the seven questions on leadership are presented in Table II. One interesting finding is the difference in the perceptions of senior leaders of Dental Corps officers who have served on an extended deployment since 2001 and those who have not had a recent deployment. Only 36% of junior officers and 66% of senior officers who had deployed thought that senior officers were taking action to address their issues. These levels of satisfaction with senior leaders addressing their issues were lower than those of their cohorts who had not been involved in a recent deployment. There were minimal differences between deployed and nondeployed officers when they rated their local leadership. The deployed versus nondeployed perceptions are presented in Table III.

Student loan indebtedness can have a detrimental effect on retention. Among the officers with dental school loans, the level of student loan debt ranged from $2,000 to $340,000. Average loan debt was inversely proportional to the number of years the officer had a HPSP scholarship, as shown in Table IV. An interesting finding was that 64% of 4-year HPSP scholarship recipients (74 of 116 recipients) still had some student loans, with an average of almost $44,000. For the captains in the 2006 survey who had dental school loans (n = 133), the average indebtedness was $67,281, with a maximum of $340,000. In addition, 77 officers reported having outstanding undergraduate student loans ranging from $1,000 to $80,000, with a mean undergraduate student loan debt of $19,941. Of the 77 officers with undergraduate loans, 70 also had dental school loans, for a mean total student loan debt of $93,355.

DISCUSSION

The results of this project indicate that there are many areas of challenge for recruiting and retaining Army Dental Corps officers. Many recent initiatives have focused on addressing the perceived pay gap with the civilian sector; these findings illustrate that pay is an important factor but it cannot be addressed in isolation. An important finding of this survey was that Dental Corps officers are not a homogeneous group and junior and senior officers have distinct and varying drivers of retention. Junior officers are much more concerned about pay than senior officers. Senior officers are more focused on the quality of dental practice, quality of life, and frequency of moving their families. The results of the surveys indicate that perceived adequate compensation is an enabler to retention of Dental Corps officers, but retention efforts cannot rely solely on pay initiatives and must focus on all needs of the officers.

One of the alarming findings of these surveys was the high student loan debt of Dental Corps officers, although a large proportion of these individuals had fully funded dental school educations with monthly stipends. The average debt for a dental student has increased dramatically, from $48,000 in 1990 to $146,000 in 2006.6 The 2004 Army Dental Corps Retention Survey found that the average school debt for captains was $56,000, with a maximal indebtedness of $250,000. We cannot explain the average debt of almost $45,000 for more than one-half of the respondents who received a fully funded dental education. Attending dental schools in expensive urban areas or costs associated with a family might have necessitated taking loans, but the overarching issue for the Army is that these loans negatively affect retention. Officers who received governmentally fully funded dental educations are not allowed to participate in student loan repayment programs and may struggle to pay those loans while on active duty. The student loan debt is exacerbated by the existence of undergraduate student loans as well. The presence of these loans and perceived low pay among Dental Corps junior officers seem to be major triggers for dentists exiting active duty service.

The effect of a 1-year deployment to a war zone is a major contributor to retention issues. We think that it is not just the actual deployment but also the threat of a deployment that hampers retention. Officers are leaving the service before they deploy because they believe that they will deploy. Recent deployments have been 12 to 15 months for general dentists and 6 months for some specialists. Throughout both surveys, dentists voiced a strong demand for 6-month deployments for all dental providers. A shortened deployment length would provide parity for all dental providers and would take officers away from their families for shorter periods of time. In January 2008, the Army enacted a new policy limiting deployments of Professional Filler System health care providers to 180 days. Dentists who are directly assigned to combat units will continue to deploy for the complete duration of that unit's deployment, which was recently changed to 12 months.

During pilot-testing, it was suggested that questions about perceptions of leadership be added. The findings were interesting, in that junior officers had much less trust in the senior leadership than did senior officers. A confounder for that finding might be that many of the senior officers who responded to the survey were senior leaders themselves. An unexpected finding was that officers who had deployed had less confidence that senior leaders were aware of their issues and were taking action on those issues. We are unsure of the explanation for this finding, although it may relate to longer deployments and the fact that not all officers have to deploy. Officers could have interpreted the questions on senior and local leadership differently, based on whether they deployed or not. The questionnaire clearly indicated that senior dental leaders were the Dental Corps chief and U.S. Army Dental Command commander and local leaders were defined as dental clinic chiefs and dental commanders, but officers could have based their answers on their deployed leadership, possibly explaining differences in leader rankings for deployed officers.

The results of this survey have limited generalizability, including the Dental Corps of the other military services. Other public health programs employing large number of dentists may draw from the conclusions. One limitation is the difference in response rates between the two surveys. There was a much better response rate for the senior officers. The junior officers might have felt threatened by the perceived lack of anonymity related to the survey process; therefore, the results could underestimate the magnitude of the retention issues.

CONCLUSIONS

The surveys found that retention of Army Dental Corps officers is multifactorial in nature. Pay is a major retention factor, but the findings showed that pay is only one factor. Future retention initiatives need to address quality of dental practice, deployment frequency and duration, quality of life issues, and pay.

The Army Dental Care System has used this information to address the concerns of all stakeholders. The results were used to change Army policy, shortening the deployment duration for many providers, and to increase special pay and accession bonus rates. Senior leaders are using the information to educate the Dental Corps through various outreach programs. These programs include holding biannual video/ teleconferences with junior and senior officers, creating opportunities for officers to attend nationally organized dentistry meetings, and creating a new conference solely for commanders.

© 2008 Association of Military Surgeons of the United States Provided by ProQuest LLC. All Rights Reserved.