Lam_Otoole_Arola Factors-Dental (Terms Of Clearance)

Terms of Clearance: Learner’s Perception Survey, 2900-0691
Lam_Otoole_Arola
Factors Associated with the Satisfaction of
Millennial-Generation Dental Residents with their
Training Experience

This document is in reference to the non-response bias analysis requested
by OMB. OMB made a second request for the lead Statistician to expound
on their previous response, by providing more detail.

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TITLE PAGE
TITLE: Factors associated with the satisfaction of Millennial-Generation
dental residents with their training experience
Authors:
1. Hwai-Tai C. Lam, Ph.D., Program Analyst, Office of Policy and Planning, US
Department of Veterans Affairs
2. Terry G. O’Toole, DDS, Director, Dental Healthcare Analysis, Office of the
Assistant Under Secretary for Health for Dentistry, Department of Veterans
Affairs, Veterans Health Administration Central Office
3. Patricia E. Arola, DDS, MHA. Assistant Under Secretary for Health for Dentistry,
Department of Veterans Affairs, Veterans Health Administration Central Office
4. T. Michael Kashner, PhD, JD, MPH. Office of Academic Affiliations, Washington,
D.C. and Research Professor, Department of Internal Medicine, Loma Linda
University School of Medicine, Loma Linda, CA
5. Barbara K. Chang, MD, MA, Director, Medical & Dental Education, Office of
Academic Affiliations, Department of Veterans Affairs, Veterans Health
Administration Central Office
Correspondance:
Hwai-Tai C Lam, Ph.D., FACHE
411 12th street, SE, Washington DC, 20003,
tel: 202-461-1080, e-mail: hwai-tai.lam@va.gov

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TITLE: Factors associated with the satisfaction of Millennial-Generation
dental residents with their training experience
ABSTRACT
Data from the 2010 Learners’ Perceptions Survey (LPS) administered through
the Office of Academic Affiliations, Department of Veterans Affairs (VA), were analyzed
to identify factors associated with dental residents satisfaction with VA as a clinical
training environment. Satisfaction scores were linked to clinic workloads, dental
procedure complexity levels, staffing patterns, and facility infrastructure data to explore
conditions that may improve residents’ satisfaction. Findings supported the construct
validity of the LPS survey data and underscored the importance of maintaining optimal
ratios of attending dentists, dental assistants, and administrative staff per resident so
that each trainee will have opportunities to perform an adequate level of dental
workload. As programs strive to improve the quality of graduate dental education,
findings from this study are vital for setting curriculum design guidelines and to
providing infrastructure support to dental resident education.

KEY WORDS
Productivity, dental assistant, operatory, workload, dental resident, graduate dental
education, employee satisfaction

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TEXT: FACTORS ASSOCIATED WITH THE SATISFACTION OF MILLENNIALGENERATION DENTAL RESIDENTS WITH THEIR TRAINING EXPERIENCE

BACKGROUND AND INTRODUCTION
The Department of Veterans Affairs (VA) has become one of the largest providers
of post-graduate education in the United States, second in funding for graduate medical
education only to the Centers for Medicare and Medicaid. Each year, VA funds over
360 full-time equivalent positions for dental residents in General Dentistry and dental
specialties. VA also assists in the training of dental hygienists, dental assistants, dental
laboratory technologists, and other dental auxiliaries in many of its 200+ modern
facilities.1 In the last five years, nearly 900,000 unique Veterans have received dental
care in a VA facility, and one-third of their clinical encounters with a dentist have
involved a dental resident. Dental residents, as part of their post-graduate training,
rotate through VA medical centers and assist in providing care to patients under the
direct clinical supervision of VA staff dentists. As a result of that clinical experience,
many of these dental residents go on to choose part- or full-time employment with VA.
All VA dental residency programs are fully accredited. Residents rotating through
VA dental clinics gain experience in a wide range of challenging dental procedures,
working under the close supervision of highly skilled general and specialty attending
faculty.2 In addition to clinical supervision and direct mentoring, residents receive
ongoing education through conferences, web-based training, and participating in
specific VA programs and research activities. Upon completion of their training, dental
residents often seek permanent VA employment; in 2009, 43% of staff dentist providers
reported obtaining at least part of their training in VA facilities.3 As Millennials tend to be

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socially committed, many may seek VA employment to serve Veterans who have
served our country.4
For the purpose of this report, we define Millennial-Generation (or Gen-Y)
residents as those who were born after 1978. Many are entering dental residency
training programs taught by Baby Boomers, and to a lesser extent, Gen-X faculty.
Recognizing that a significant generation gap in culture, values, and motivators exists
between the Baby Boomers and Millennials,5 designing curriculum to meet the
Millennials’ needs and to attract them to work for VA after training requires an
understanding of this new generation‘s satisfaction factors. The Office of Academic
Affiliations (OAA) strives to improve dental residents’ satisfaction through closely
monitoring the breadth, volume, and quality of dental procedures performed by dental
residents. To gain additional insight into the resident experience, OAA also conducts
the VA Learners’ Perceptions Survey (LPS), a voluntary, anonymous, web-based
survey administered annually since 2001,. The survey is administered to both dental
and physician residents, as well as to nursing and associated health trainees, who
rotated through a VA medical center from an approved training program. 6 The present
study was designed to explore the satisfaction factors of dental residents who rotated
through a VA medical center in 2010. Data is derived from dental residents’ responses
in the VA’s Learners’ Perceptions Survey (LPS).
Hypotheses & Research Questions
The literature shows that upon completion of a graduate dental residency
program, the average trainee has incurred debt of over $165,226.7 Dental residents,
who spend additional post-graduate years to advance their clinical skills through

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exposure to a wide range of dental procedures and challenges will do so by forgoing
opportunities to earn income by not entering dental practice directly upon graduation.8
Thus, residents are expected to avoid performing non-clinical functions, such as
preparing operatories, coordinating follow-up appointments for patients, or answering
phone calls. In this paper, we hypothesized that sufficient administrative and auxiliary
support at the dental clinics would spare residents from performing non-clinical
functions and assure satisfaction. Likewise, we also hypothesized that residents would
be satisfied if they had sufficient exposure to high-complexity procedures.
In order to inform program administrators and policy makers concerning
development of dental resident training guidelines, we examined the hypotheses that
dental clinic workload, staffing support, and clinic infrastructure will impact dental
resident satisfaction ratings with their clinical training and working environments.
Workload is measured as the number of dental procedures, the complexity of those
procedures, relative resident and overall clinic productivities, and the percentage of total
workload performed by residents. Staffing support is measured using two ratios: dental
assistants to dentists and clinic clerks to dentists. Infrastructure support is measured
using the ratio of dental operatories to dentists. If associations existed, we further
tested to see if these associations are monotonic across the range of workload and
staffing support to detect if stable optimal levels exist that maximize satisfaction rates.

METHODS
Study Design

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Study data is derived from the Department of Veterans Affairs Learners’
Perceptions Survey (LPS) administered to all dental resident trainees who rotated
through a VA medical facility in AY 2010.
The LPS is an Office of Management and Budget approved,9 standardized, webbased survey designed to assess the satisfaction of health professions trainees who
rotate through a VA medical center during each academic year. These rotations are
covered under affiliation agreements between the VA and accredited sponsoring
hospitals or university-based education programs. The Veterans Health Administration
Office of Academic Affiliations (OAA) has administered the LPS annually since 2001 for
evaluative, regulatory, program administration, and policy-making purposes under its
National Evaluation Workgroup. The LPS has good internal consistencies (α’s ranging
from 0.87 to 0.92), which have been validated for discriminant validity across clinical
specialties 10,11, 12 and for construct validity. 13
For purposes of this study, we examined two LPS environments across six
domains involving a total of 75 element questions. Specifically, we focused on the
learning environment (comprising clinical learning and training experience) compared to
non-VAs, faculty/preceptor domains, and the working environment (comprising work,
physical, and personal experience domains). Each domain consists of an overall
summary question that is asked following responses to 9 to 15 element questions about
specific items that define the domain. All questions are asked on a five-point Likert
scale.
Descriptive analyses were first performed to explore the six domains of the LPS.
The frequencies of negative responses were tallied to identify areas that need

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improvements. To assess the relative importance of the six domains with the overall
satisfaction, a linear regression model was constructed using the overall satisfaction
score from 1 to 100 as the dependent variable, and the six domain scores as the
independent variables.
The relative importance of each detailed question under one domain was
assessed by constructing logistic regression models using each domain score as the
dependent variable and scores for each question as the independent variables. After
merging the LPS individual scores with facility-level staffing, operatories, workloads, and
dental procedure complexity data, the data were clustered by facility for analyses.
Variations among the significant LPS factors were then explained by the workload,
complexity of dental procedures, staff support, operatory ratios, and percentage of
workload performed by residents through logistic regression models clustered by clinics.
This research was granted an exemption from Institutional Review Board (IRB)
oversight, as the information obtained precluded identification of individual subjects;
furthermore, the research itself was non-interventional, occurring in established
education settings and involving usual education practices.
Data Sources
The LPS data for academic year (AY) 2010, from July 1, 2009 to June 30, 2010,
was provided by the Office of Academic Affiliations. Analyses were limited to dental
residents’ responses. The 5-point Likert-scale scores ranged from 1 to 5, where 5
indicated “very dissatisfied” and 1 indicated “very satisfied.” Workload data for the
same academic year 2010 was obtained from VA’s Dental Encounter System (DES).
Dental procedures in DES are coded using standard CDT/CPT codes and collected at

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the encounter level. If one patient is treated by two providers at a single dental visit,
there are distinct encounter records created to reflect the workload for each provider.
Additionally, individual dental procedures are mapped to a standardized Relative Value
Unit (RVU) representing the relative work effort, time, and complexity of the procedure.
Dental staffing data were obtained as cumulative fulltime employee equivalents (FTEE)
from payroll data. Available operatory data was obtained from each facility in a selfreported survey.
Dental procedures were categorized into three industry standard complexity
levels by CDT/CPT codes: basic/preventive procedures, minor procedures, and major
procedures. Examples of these three complexity level procedures are exhibited in Table
1. The relative percentages of procedural complexity (total RVUs of major
procedures/total RVUs) were derived at the clinic level to reflect the complexity level of
procedures available to residents either by observation or hands-on operation.

RESULTS
In AY2010 (June 30, 2009 to July 1, 2010), 184 dental residents responded to the
LPS, yielding a response rate of 52%. Data included 74 survey respondents who
completed their rotations before the end of AY2011. The respondents were 56% male
and 44% female. The majority (93%) of the respondents rated their recent VA clinical
training experience as “Very good” or “Excellent.”
To examine issues of validity raised with our 52% response rate, we assessed the
validity of LPS domain responses by estimating linear regression models that were
designed to compare the six domains representing training and working environments

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on an overall VA experience satisfaction scale. The VA experience scale was
computed on a 100-point scale provided with the LPS survey data. Here, higher scores
indicate greater satisfaction. Respondents were informed that a “passing” score is 70.
Among these respondents, 82% rated their experience at 80 or above, with an overall
average score of 86.6. As presented in Table 2, three domain scores (clinical
faculty/preceptors, VA clinical training experience against non-VA, and working
environment) explained 70% of the explained variance of these 100-point VA
experience satisfaction scores.
Every detailed question under each domain significantly correlated with its overall
domain score, attesting to the validity of the survey questions. We constructed logistic
regressions using the binary domain score as the dependent variable and scores from
the detailed questions under each domain as independent variables. The results are
presented in Tables 3 through 8.
The results of this study are further discussed under the context of each of the six
survey domains.
Domain of Learning Environment
The domain of learning environment significantly correlated with the overall
satisfaction (r=0.78, t < 0.001); however, when controlling for the impact of other
domains, its relative impact was not statistically significant. Within this domain, six
aspects explained 76% of satisfaction variations for learning the environment: (1)
Amount of non-educational (“scut”) work, (2) Preparation for future training, (3) Time for
learning, (4) Access to specialty expertise, (5) Culture of patient safety, and (6)
Spectrum of patient problems. “Preparation of business aspects of clinical practice”

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scored the lowest, with 60% responding “Somewhat satisfied” or “Very satisfied,” and
residents did not consider this aspect as relatively important to their satisfaction. The
“Amount of non-educational (“scut”) work” significantly impacted the satisfaction score
of this domain, with satisfaction in this aspect scoring relatively low (76%, Table 3).
Since clinic clerks and dental assistants perform non-dentist tasks of coordinating
patients and preparing instruments, their staffing ratio to dentists were analyzed. The
ratio of assistants to dentists significantly impacted the overall learning environment
satisfaction score (Wald Chi-Square =5.16, p=0.02), but satisfaction of this domain had
no association with the clerks-to-dentists ratio or with the operatory rooms-to-dentists
ratio.
Domain of Physical Environment
Physical environment associated significantly with the overall satisfaction score
(r=0.64, p<0.0001), despite its relative insignificance when controlling for other domains.
Within this domain, five detailed questions impact the satisfaction significantly: (1)
Availability of needed equipment, (2) Heating and air conditioning, (3) Facility
cleanliness/housekeeping, and (4) Availability of food at medical center when on call
(Table 4). The low score of parking (63.3%) did not impact the satisfaction of residents
as significantly as heating and air conditioning (79.3%), perhaps because room
temperature arouses discomfort for a longer period of time than the short duration of
frustration searching for a parking space. The relatively low satisfaction for the
“availability of food at medical center when on call” (65%) has been noted from previous
surveys, as many VA cafeterias close prior to dinner time.

Since dental assistants

typically prepare the treatment room, dental equipment, and instruments for dentists,

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the dental assistant-to-dentist ratio was analyzed further to explain the variations on the
satisfaction score of “Availability of needed equipment.” The finding showed no
association. Thus, it appeared that the dissatisfaction was due to the physical
unavailability of necessary equipment rather than ready access to equipment as
facilitated by the dental assistants.
Domain of Working Environment
This domain significantly impacts overall resident satisfaction and therefore
warrants close monitoring. As Millennials value a team environment, “Peer group
morale” impacts the satisfaction significantly. This area scored a high 90%. The other
two aspects that significantly impact the working environment satisfaction were
“Orientation Program” and “Workspace.” (Table 5) Work space received an 88% rate of
“Somewhat satisfied” or “Very satisfied” ratings. In VA dental clinics, the average ratio
of operatory to dentist, including residents, is one to one, which was below the optimal
ratio of two to one from a productivity perspective, but was not low enough to cause
dissatisfaction from residents.
Satisfaction ratings for "Ancillary/support staff" and "Orientation program" both
scored relatively low. These two low scores were associated with “amount of scut work”
in the “Physical Environment domain” (r > 0.46, p < 0.0001), indicating areas for
improvements. To explore further, the ratio of dental assistants to dentists was used as
a proxy for ancillary support. Analyses were done by using ancillary/support staff
morale score as the dependent variable and dental assistants-to-dentists ratio and clinic
clerks- to-dentists ratio as the independent variables in a logistic model clustered by
clinics. The dental assistant ratio showed significant positive impact on the

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ancillary/support staff morale score (Wald Chi Square = 5.408, p=0.0201), but no impact
by the clinic clerks-to-dentists ratio. This indicated that dental assistants play a more
significant role in providing ancillary support than clinic clerks do. Without an effective
orientation program and supportive ancillary staff, residents can waste time acclimating
to a new clinic environment.
It is widely accepted that the Millennial generation is computer savvy. Because a
VA has long been known in the healthcare industry for its advanced computerized
patient record system (CPRS), it was hypothesized that VA’s CPRS contributes to high
satisfaction among residents. Nevertheless, despite the fact that satisfaction scores
were high (91.5%) for CPRS, this element did not significantly impact the working
environment satisfaction. Our results suggest that the Millennial Generation takes
advanced computer technology for granted and that computer technology has become
a “hygiene” factor. That is, the presence of technology does not impact satisfaction, but
the absence of it could certainly produce dissatisfaction.14

Domain of Personal Experience
The Personal Experience Domain was associated significantly with the overall
satisfaction score (r=0.77, p=<0.0001). The rating for personal experience at VA was
high, with 94% of respondents rating their experience as “Somewhat satisfied” or “Very
satisfied.” Factors significantly impacting the satisfaction of this domain include (1)
Personal support, (2) Personal award, and (3) Ownership and responsibility for patients’
care, (Table 6). These results supported literature findings for the Millennial generation.
They pursue opportunities to expand their skills and experience, and financial incentives

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are less of a motivator than for older generations who had lived through recession and
depression. The Millennial generation is often called the “Trophy” generation, being
reared with constant and immediate praise and rewards.15 Millennials demand a lot of
personal attention. It is likely that they will leave if they do not receive adequate
attention and recognition; therefore, the amount and frequency of feedback that they
receive from faculty may play an important role in their satisfaction, workforce
recruitment, and retention.16
In VA teaching clinics, the attending dentist-to-resident ratio averaged 2:1, which
was adequate to receive 94% favorable responses for personal support, and 92% for
personal award (Table 6). In order to calculate the optimal ratio of attending dentist-toresident ratio, a logistic regression model was constructed using that ratio as an
independent variable. The result showed significant negative impact on satisfaction
score of this domain, which was contradictory to our hypothesis that the higher this
ratio, the higher the satisfaction score on personal experience.,
Factors not significantly impacting resident satisfaction in the personal
experience domain included relationships with patients, continuity of relationships with
patients, and the quality of care that the respondent’s patients receive. Additional study
would be necessary to determine whether this finding is a function of the transient
nature of resident education or whether Millenials view the provider-patient relationship
differently than other provider generations. In contrast to literature describing Millenials,
factors related to the aspects of “balance of personal and professional life” and “level of
job stress” did not appear in this survey as significant.

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Domain Comparing the Most Recent VA Clinical Training Experience to Non-VA
Clinical Training Experience at the Same or Equivalent Level
As VA strives to be the employer of choice, information generated in this domain
is extremely important for VA’s recruitment and succession planning. Overall,
respondents rated their VA clinical training experience about the same as their non-VA
experience. Forty percent of respondents gave VA ratings of “somewhat better” or “a lot
better,” but 38% rated their VA and non-VA experience “about the same.” These
results were consistent with two other survey questions in that respondents were asked
to rate VA and non-VA residency programs on a numerical scale of 1-100. The
difference was 1.5 points in favor of VA, but was not statistically significant. The
literature states that those of the Millennial Generation switch jobs frequently and
constantly seek opportunities to strengthen their skills. These descriptions of the
Millennial Generation are supported in that the “usefulness of what respondent learned”
was significant in impacting satisfaction (r=0.44, p=0.0001). The other two significant
aspects were “Clinical Faculty” and “Working Environment.” (Table 7) When analyzed
with clinic-level staffing and workload data, two measures significantly impacted the
satisfaction scores in this domain positively: residents’ total workloads (Wald ChiSquare = 15.01, p=0.0001) and clinic clerks-to-dentists ratio (Wald Chi-square = 15.4,
p<0.0001). Both factors can be monitored to assure satisfaction.
Domain of Clinical Faculty/Preceptors
Similar to other surgical residencies, a dental residency is in large part a
procedure-oriented apprenticeship with residents working closely with attending faculty.
Most dental residents (94%) were “Somewhat satisfied” or “Very satisfied” with their

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dental clinical faculty. Three significant aspects for faculty are: Clinical skills, Interest in
teaching, and Quality of faculty. All three areas scored above 85% with somewhat or
very satisfied. (Table 8) The area that needs improvement in this domain is the
“Research Mentoring,” which had only 65% responses as “Somewhat satisfied” or “Very
satisfied.”
In VA teaching dental clinics, the average ratio of two faculty attending to one
resident is sufficient to allow residents to receive timely feedback and adequate
mentoring; however, the higher attending-to-resident ratio, the lower the satisfaction
score in this domain.
Association of Clinic Staffing Patterns, Procedure Complexity with Overall Satisfaction
Staffing patterns and procedure complexity can be adjusted administratively to
assure residents’ satisfaction; therefore, logistic regression models were constructed to
analyze the association with satisfaction. The results indicated that two clinic staffing
ratios significantly and positively impacted the overall score of satisfaction: dental
assistants-to dentists-ratio (estimate=16.64, p=0.0080, Figure 1), and clerks-to-dentists
ratio (estimate = 64.32, p=0.0099, Figure 2). It was assumed that residents could
receive more personal attention when attending dentists-to residents-ratio was high,
and have more training opportunities when major-complexity level of dental procedures
was high. We, therefore, hypothesized both factors be positively associated with
residents’ satisfaction. Contrary to the hypotheses, the attending dentists-to-residents
ratio was associated negatively with the overall satisfaction score (estimate = -1.86,
p=0.0002), and the percentage of dental procedures with major-complexity level had no
impact with residents’ overall satisfaction scores. Reasons for these surprised findings

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were explored further. The results showed that the attending-to-resident ratio was
negatively associated with the proportion of clinic workload done by residents (r=-0.48,
p<0.0001), which indicated lesser chance for residents to provide dental care to patients
when the ratio is high. Non-resident dentists’ workloads consist of an average of 37%
major complexity dental procedures, which was significantly higher than the average
32% of major complexity dental procedures done by residents.
Association of Productivity with Resident Satisfaction
Millennials have been described to work best in a “team” environment, while
Baby Boomers tend to pursue individual accomplishments.14 The “Team” productivity for
each dental clinic was explored to examine the association with residents’ satisfaction.
The total RVUs produced by the clinics were divided by the FTEE (full time employee
equivalent) of the total staff dentists plus the total number of residents). The results
showed that resident-team productivity was negatively associated with residents’ overall
satisfaction scores (Z = -2.98, p=0.0028). The cross-sectional study design in this study
did not allow any interpretation for causal relation; however, the findings were contrary
to the workforce motivation Theory-Y that “Happy workers are productive workers15,”
and were explored further.
After controlling for dental assistants to dentists ratio, clinic team productivity was
found to be negatively impacted by the number of residents in the clinics (Z = -6.95,
p<0.0001) and the resident workload-to-total clinic workload ratio (Z=-2.87, p =0.0041).
Staff dentists had 45% higher productivity than residents. The higher the faculty-toresident ratio, the higher the clinic productivity was; however, the higher the productivity

In press, Journal of Dental Education 17
the lesser percentage of workload performed by residents (Z=-2.87, p<0.0041), and the
lower the residents’ overall satisfaction (r=-0.279, p=0.0019).
Association of Percentage of Workload Done by Residents with Satisfaction
What associated positively with residents’ satisfaction scores was the percentage
of total workload performed by residents (estimate = 10.9, p=0.041, figure 3). While
percentage of major procedures indicates the learning opportunities of residents, the
percentage of workload done by residents reflected what actually happened at the
dental clinics and directly measured the hands-on opportunities with which residents
were entrusted and supervised by faculty. The percentage of resident-performed
workload impacted the overall satisfaction scores and the following learning aspects:
“time for learning,” “personal award,” “ownership/personal responsibility for patient care,
” “clinical faculty’s interest in teaching,” “enhancement of clinical knowledge and skills,”
“usefulness of what residents learned compared to non-VA,” and ”VA clinical faculty
compared to non-VA training sites” ( Table 9 and Figure 3). The percentage of workload
done by residents had no significant association with the percent of major dental
procedures, which also had no impact on overall satisfaction. In year 2010, on average,
dental residents performed 36% of workload in VA dental clinics, with a median of 40%
and a maximum of 63%. Since our dataset is cross-sectional and non-causal, the
highest ratio was associated with the highest satisfaction, we were not able to estimate
the optimal ratio of the portion of workload distributed to residents.
CONCLUSIONS
The purpose of this study was to explore the impact of workload and staffing data
on factors associated with Millennial-Generation dental residents’ satisfaction. This

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study is especially important. During the coming decade, VA‘s workforce will
increasingly depend on Millennial generation residents to fill positions vacated by
retiring Baby Boomers. Hence, the satisfaction of Millennial generation residents is
likely to impact recruitment.
Overall, on a scale of 1-100, dental residents gave an average score of 86.6 for
their VA clinical experience and an average score of 85.1 for their non-VA training.
Three domains were shown to demonstrate significant impact on the overall dental
residents’ satisfaction: (1) Working environment, (2) Ratings of clinical
faculty/preceptors, and (3) Comparison of VA clinical training experience with non-VA.
Two staffing ratios were positively associated with the overall satisfaction: the ratio of
dental assistants to dentists and the ratio of clinic clerks to dentists. In our previous
research, the optimal ratio for dental assistants to dentists to maximize productivity is
1.5:1, and the optimal clerical staff to dentist ratio to maximize productivity was 0.57
clerks per one dentist.18 This study further demonstrates that these staffing ratios are
not only important for productivity, but also significantly impact resident satisfaction.
The current ratio of two attending dentists to one resident is adequate to obtain
satisfaction on personal support and personal award for residents; however, that ratio
was associated negatively with overall satisfaction scores, despite that it reflects the
potential of providing higher personal attention and learning opportunities to residents.
What was associated positively with the satisfaction scores was the percentage of clinic
workload performed by residents, with the highest resident satisfaction score being
associated with 63% of workloads being delegated to residents. The residents’ workload
proportion was negatively associated with the attending-to-resident ratio. The higher

In press, Journal of Dental Education 19
the ratio, the less proportion of workload was distributed to residents and may be the
underlying cause for the negative impact of the attending-to-resident ratio on residents’
satisfaction.
This study identified the significant elements within each domain of the LPS that
had the greatest impact on dental residents’ satisfaction. The information should be
helpful in designing residency program curriculum and quality assurance programs.
Ancillary support of clinic clerks and dental assistants are essential for residents’
learning environment. The percentage of workload performed by residents could be
used as an outcome measure for the quality of resident teaching as it significantly
impacted residents’ satisfaction.

In press, Journal of Dental Education 20

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Http://www.asiaone.com/Business/Office/Learn/A1Story20080511-64480.html.
May 12, 2008.
17.Howe, Neil and Strauss, William. Millennials Rising. 2000, p. 180. Vintage Books,

A division of Random House, Inc. New York.

In press, Journal of Dental Education 22
18.Dental Benefits for Veterans, VA Health Care Fact Sheet, 164-3, September

2010. http://www.va.gov/healtheligibility/Library/pubs/Dental/Dental.pdf
19.Hwai-Tai C. Lam, Ph.D., Timothy Ward, MA, DDS, Terry G. O’Toole, DDS,

Patricia E. Arola, DDS, MHA, Barbara K. Chang, MD, MA. Impact of
Infrastructure on Graduate Dental Education. Journal of Dental Education,
2009:73(2):184-191.
20.Douglas McGregor: Theory X and Theory Y. Workforce; Jan2002, Vol. 81 Issue

1, p32,1/4p,1 bw.

In press, Journal of Dental Education 23

ACKNOWLEDGEMENT
We are grateful to Malcolm Cox, M.D. , William J. Marks, M.D. and Karen M. Sanders, M.D. of
the Office of Academic Affiliations, Veterans Health Administration, for their reviews and
helpful comments. We thank the following scholars for their advice on data analyses: Ted
Stefos, Ph.D., Charles Lin, Ph.D., and David Chan, M.D..

In press, Journal of Dental Education 24

Table 1. Examples of three-complexity levels of dental procedures

Dental Procedure Category 

Preventive and Basic Dental Services

Minor Restorative Dental Services

Major Restorative Dental Services

CPT Code 

RVU

D0120 - PERIODIC ORAL EVALUATION

30

D0150 - COMPREHENSVE ORAL EVALUATION

45

D0160 - EXTENSV ORAL EVAL PROB FOCUS

45

D0170 - RE-EVAL,EST PT,PROBLEM FOCUS

20

D0180 - COMP PERIODONTAL EVALUATION

45

D1510 - SPACE MAINTAINER FXD UNILAT

45

D1515 - FIXED BILAT SPACE MAINTAINER

60

D1520 - REMOVE UNILAT SPACE MAINTAIN

45

D2140 - AMALGAM ONE SURFACE PERMANEN

35

D2330 - RESIN ONE SURFACE-ANTERIOR

35

D2410 - DENTAL GOLD FOIL ONE SURFACE

80

D2510 - DENTAL INLAY METALIC 1 SURF

100

D2644 - DENTAL ONLAY PORC 4/MORE SUR

150

D2650 - INLAY COMPOSITE/RESIN ONE SU

120

D2652 - DENTAL INLAY RESIN 3/MRE SUR

160

In press, Journal of Dental Education 25

Table 2. Relative impact of the six domains on the overall satisfaction score 
Domain 

Statistical Significance 

Work  environment at VA facility 

Yes (t=6.34, p < 0.0001) 

Clinical Faculty/Preceptors at VA facility 

Yes (t=3.58, p = 0.0006) 

Comparison of most recent clinical training 
experience with VA to non‐VA 

Yes (t=3.48, p = 0.0009) 

Personal Experience at VA facility 

No 

Physical environment at VA facility 

No 

Learning Environment at VA facility 

No 

In press, Journal of Dental Education 26
Table 3.  Relatively impact of the domain factors on the Learning Environment satisfaction 
scores 

% Somewhat or 
LEARNING ENVIRONMENT 

Statistical Significance 
Very Satisfied 

Amount of non‐educational ("scut") work 

Yes (chi‐Sq = 9.51, p<0.0020) 

76% 

Preparation for future training 

Yes (Chi‐Sq =21.85, p<0.0001) 

92% 

Time for learning 

Yes (Chi‐Sq=4.95, p=0.0261) 

87% 

Access to specialty expertise 

Yes (Chi Sq=5.00, p=0.0252) 

89% 

Diversity of Patients 

Yes (Chi‐Sq = 3.66, p=0.0557) 

88% 

Culture of patient safety 

No 

94% 

Spectrum of patient problems 

No 

96% 

Working with patients 

No 

96% 

Degree of supervision 

No 

91% 

Degree of autonomy 

No 

94% 

Interdisciplinary approach 

No 

88% 

Preparation for clinical practice 

No 

91% 

No 

60% 

Teaching conferences 

No 

84% 

Quality of care 

No 

94% 

Preparation of business aspects of clinical 
practice 

In press, Journal of Dental Education 27

Table 4. Relative impact of the domain factors on the Physical Environment satisfaction
scores

% Somewhat 
Physical Environment 

Statistical Significance 

or Very 
Satisfied 

Availability of needed equipment 

Yes (Chi‐Sq=4.31, p=0.0379) 

83% 

Heating and air conditioning 

Yes (Chi‐Sq=5.24, p=0.0221) 

79% 

Facility cleanliness/housekeeping 

Yes (Chi‐Sq=8.72, p=0.0032) 

83% 

Availability of food at medical center when 

Yes (Chi‐Sq=5.78, p=0.0161) 

65% 

on call 

Lighting 

No 

91% 

Convenience of facility location 

No 

94% 

Parking 

No 

63% 

Personal safety 

No 

92% 

Availability of phones 

No 

94% 

Maintenance of equipment 

No 

82% 

Facility maintenance upkeep 

No 

85% 

Call rooms 

No 

82% 

In press, Journal of Dental Education 28

Table 5. Relative impact of domain factors on Working Environment
satisfaction scores

Working Environment 

Faculty/preceptor morale
Peer group morale
Ancillary/support staff
Orientation program
Computer access
Internet access
Ancillary/support staff morale
Laboratory services
Radiology services
Call schedule
Computerized Patient Record System (CPRA)
Library services
Workspace

Statistical  

Significance 

Yes (t=3.01, p=0.0029) 

Yes (t=5.59, p<0.0001) 

Yes (t=5.78, p<0.0001) 

Yes (t=4.28, p<0.0001) 

Yes (t=5.87, p<0.0001) 

Yes (t=6.43, p<0.0001) 

No 

No 

No 

No 

No 

                     No 

No 

% Somewhat 
or 

Very Satisfied 

89.9% 

89.8% 

71.5% 

77.2% 

90.2% 

88.5% 

71.5% 

84.8% 

81.1% 

88.6% 

91.5% 

79.9% 

87.8% 

In press, Journal of Dental Education 29
Table 6. Relative impact of domain factors on the Personal Experience at VA facility
satisfaction scores

Personal Experience

Personal support
Personal award
Ownership/personal responsibility for

Statistical Significance
Yes (Chi-Sq=5.45,
p=0.0195)
Yes (Chi-Sq=5.39,
p=0.0201)

%
Somewhat
or Very
Satisfied
94%
92%

Yes (Chi-Sq=4.94,
p=0.0263)

94%

Quality of care respondent's patients
receive

No

96%

Relationship with patients

No

97%

No

94%

No

87%

No

98%

Level of fatigue

No

85%

Balance of personal and professional
life

No

93%

Enjoyment of respondent's work

No

94%

Level of job stress

No

86%

No

91%

respondent's patients' care

Enhancement of respondent's clinical
knowledge and skills
Appreciation of respondent's work by
faculty
Appreciation of respondent's work by
patients

Continuity of relationship with patients

In press, Journal of Dental Education 30
Table 7. Relative impact of the domain factors on VA Clinical Training Experience
compared with non-VA satisfaction scores
VA Clinical Training  

Experience compared  

with non‐VA's 

Clinical faculty 

Usefulness of what  

respondent learned 

Working environment 

Learning environment 

Degree of supervision 

Faculty staff 

Physical environment 

Degree of autonomy 

Quality of care 

Statistical Significance 

% 
Somewhat 
or a lot 
better than 
non‐VA 

Yes (Chi‐Sq=17.78, p<0.0001) 

34% 

Yes (Chi‐Sq=6.22, p<0.0126) 

43% 

Yes (Chi‐Sq=4.73, p<0.0296) 

39% 

No 

No 

No 

No 

No 

39% 

41% 

34% 

33% 

44% 

No 

36% 

In press, Journal of Dental Education 31

Table 8. Relative impact of the domain factors on Clinical Faculty/Preceptors
satisfaction scores

Clinical skills

Yes (Chi‐Sq=4.23, P=0.0395) 

% Somewhat or Very 
Satisfied 
97% 

Interest in teaching

Yes (Chi‐Sq=5.04, p=0.0247) 

87% 

Quality of faculty

Yes (Chi‐Sq=5.49, P=0.0190) 

89% 

No 

No 

No 

No 

No 

No 

No 

No 

No 

88% 

88% 

93% 

90% 

65% 

90% 

94% 

94% 

90% 

                          No 

                 94% 

Clinical Faculty/Preceptors  

Mentoring by faculty
Evidence-based clinical practice
Timeliness of feedback
Teaching ability
Research mentoring
Accessibility/availability
Approachability/openness
Fairness in evaluation
Role models
Patient-oriented

Statistical Significance 

In press, Journal of Dental Education 32

Table 9. Factors associated with the percentage of workload done by residents

Linear

P

Association

Value

Overall Satisfaction Score

0.22

0.023

Time for Learning

0.14

0.039

Personal Experience at VA facilities

0.21

0.001

Personal Award

0.19

0.003

Ownership/Personal responsibility for patient care

0.19

0.003

Clinical Faculty interest in teaching

0.19

0.002

Enhancement of clinical knowledge and skills

0.16

0.017

VA Clinical faculty compared to non-VA

0.30

0.012

Usefulness of what learned compared to non-VA

0.25

0.043

Satisfaction Aspects

In press, Journal of Dental Education 33

In press, Journal of Dental Education 34

In press, Journal of Dental Education 35