HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Thind, A. Articles by Andersen, R. Search for Related Content PubMed PubMed Citation Articles by Thind, A. Articles by Andersen, R.

What Determines Positive Student Perceptions of Extramural Clinical Rotations? An Analysis Using 2003 ADEA Senior Survey Data

Dr. Thind is Associate Professor, Department of Health Services, School of Public Health; Dr. Atchison is Professor, School of Dentistry and School of Public Health; and Dr. Andersen is Professor, Department of Health Services, School of Public Health—all at the University of California, Los Angeles. Direct correspondence and requests for reprints to Dr. Kathryn Atchison, UCLA School of Dentistry, Room 63-025 CHS, 10833 Le Conte Ave., Box 951668, Los Angeles, CA 90095-1668; 310-825-4443 phone; 310-206-5539 fax; kathya{at}dent.ucla.edu.

Key words: extramural rotations, student perceptions, ADEA Senior Survey

Submitted for publication 09/10/04; accepted 12/17/04

	Abstract

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

 
Extramural clinical rotations are an integral part of many dental school curricula. Schools in The Robert Wood Johnson Foundation/The California Endowment Pipeline, Profession, and Practice program are increasing student extramural opportunities to expose students to patients of different needs, cultures, and dental delivery modes. Using data from the American Dental Education Association (ADEA) 2003 Senior Survey, the Pipeline, Profession, and Practice National Evaluation Team studied graduating dental students’ perceptions about their extramural rotations. This analysis was designed to determine the factors associated with students’ perception of their extramural clinical rotations: was it a positive experience in their dental education, and did it improve students’ perceptions of their ability to provide care for racially, ethnically, and culturally diverse groups? The respondents were 2,950 graduating seniors who reported at least one week of extramural rotation experience. After controlling for both individual and school level characteristics, this study found that race/ethnicity, a stronger socially conscious attitudes score, number of weeks spent in extramural rotations, and the student’s rating of time spent in extramural rotations were significant determinants of the extramural rotations being reported as positive experiences. With respect to improving students’ ability to provide care to racially, ethnically, and culturally diverse groups, more positive student socially conscious attitudes, a greater number of weeks spent in the rotations, a stronger service orientation for selecting dentistry as a career, and the students’ rating of their time spent in extramural rotations were significant determinants. In conclusion, there is some evidence that time spent in extramural rotations may be perceived as positive dental school experiences and, for some students, may prepare them to work effectively with culturally diverse patients by the time of dental school graduation.

Recently, there has been a growing movement to further increase the quality and quantity of extramural rotations, in an attempt to lessen disparities in access to oral health care. Extramural rotations are viewed as an outreach vehicle to place dental clinics in locations where low cost dental services are needed, to further the diversity of the patients seen, and to provide much needed cases for teaching.

The Robert Wood Johnson Foundation (RWJF) awarded $15 million to eleven dental schools in 2002 as part of its Pipeline, Professions, and Practice Program. This program is focused on increasing the number of underrepresented minority dental providers and increasing dental services provided to underserved communities, to be achieved in part by increasing the time spent in extramural rotations. Less than a year later, The California Endowment expanded the program by funding the four remaining California dental schools. In addition to the RWJF goals, the foundation extended a goal to develop health policy leadership within the dental schools.

As the national evaluator (National Evaluation Team or NET) for the Pipeline project, the UCLA School of Public Health was selected to conduct a comprehensive evaluation of the program. The NET, in conjunction with the American Dental Education Association (ADEA), devised questions for the ADEA Senior Survey that pertained to the recruitment, retention, and clinical service provision components of the RWJF program. These were adopted, and the revised ADEA survey was administered for the first time in 2003.

The ADEA survey offers an opportunity to ascertain graduating dental students’ perceptions about their extramural rotations at a national level and will serve as baseline data as the Pipeline project moves forward. The research questions of this study were the following: a) what factors are associated with the extramural clinical rotations being perceived to be a positive experience in their dental education? and b) what factors are associated with the extramural clinical rotations being perceived to improve their ability to provide care for racially, ethnically, and culturally diverse groups?

	Materials and Methods

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

 
We used the 2003 ADEA survey of dental school seniors for our baseline analyses. The ADEA survey of graduating seniors is conducted annually as a means of gaining information about changes to the student population on financing of dental education, career plans following dental school, factors that influence postgraduate plans, and student impressions regarding areas of predoctoral education.⁶ Distribution of the survey involves a joint cooperative effort of ADEA and the dental schools. Dental schools receive the packet of surveys from ADEA and distribute them in their own selected manner between February and the end of the school year. ADEA worked with the NET to add a series of questions to the 2003 survey that ascertained students’ perceptions of the community-based dental education (extramural clinical rotation) component of their dental school training.

The framework underlying the analyses posits that students’ perceptions about their extramural rotations are dependent on individual and school level factors (Figure 1).

View larger version (30K): [in this window] [in a new window]   Figure 1. Conceptual model

Independent variables.
At the individual student level, variables included age (in years), gender, marital status (married or not married), and whether the parent(s) was a dentist. Race was classified into three categories: 1) white non-Hispanic, 2) Asian and Pacific Islander, and 3) Native American, Black, or Hispanic. Total educational debt upon graduation from dental school was measured in dollars.

To control for student perceptions and attitudes, we created two scales—one that measured how strong service was to the student as a reason for joining dentistry ("service orientation") and a "socially conscious attitudes" scale. The ADEA survey asks students to rate (on a scale of 1–5, with 1 being low and 5 being high) the importance of the following reasons for their choosing dentistry as a career: opportunity for self-employment, service to others, high income potential, community status and prestige, enjoy working with my hands, variety of career options in dentistry, service to my own race or ethnic group, control of my time in relation to family and personal interest, and opportunity to serve vulnerable and low-income populations. The service orientation scale was conceptualized based on a factor analysis of the response to this question. Three reasons clearly loaded on the first factor—service to others, service to my own race or ethnic group, and opportunity to serve vulnerable and low-income populations—and these were used in the creation of the scale. These factor loadings make conceptual sense: while service to others is clearly altruistic, service to my own race or ethnic group is altruistic when viewed from the perspective of the community. Scores on this scale could range from a low of 3 to a high of 15, with a higher score indicating a more altruistic or service-oriented reason for selecting dentistry as a career. A Cronbach’s alpha or a scale reliability coefficient was calculated to test the internal consistency or square of the correlation between the measured scale and the underlying factor the scale was designed to measure.

The socially conscious attitude scale was based on responses to the question asking students if they agreed strongly, agreed, disagreed, or disagreed strongly to a set of statements about oral health care. Factor analyses revealed that four statements—access to oral health care is a societal good and right, access to oral health care is a major problem in the United States, ensuring and providing care to all segments of society is an ethical and professional obligation, and everyone is entitled to receive basic oral health care regardless of his or her ability to pay—loaded strongly on the first factor, and these were used to construct a scale. (Responses to this item that were not used were: you are prepared to accept and respect patients of different races, ethnicities, and cultures; you are prepared to integrate knowledge regarding cultural differences into treatment planning and care delivery; the cultural and social environment of your school promotes the acceptance and respect of students and patients of different races, ethnicities, and cultures; low-income underserved individuals and populations are more challenging to serve because they present with many problems; and providing oral health care to underserved individuals is challenging because they often lack personal or public financial resources to pay for it.)

Scores could range from a low of 4 to a high of 16, with a higher score indicating a more socially conscious attitude. To best capture variation in the data, we converted the scores into quartiles, with the first quartile indicating low social consciousness and the fourth quartile the highest.

School level variables included both structure and process variables. The structure variable was captured by noting if the school was part of the RWJF/TCE Pipeline project. This item was chosen to see if there were differences between schools in the demonstration programs and those that were not. Pipeline schools had all agreed to increase the length of time spent in extramural rotations, and this variable was proposed as a measure in the evaluation. School level process variables included the weeks spent in extramural clinical rotations (one to two, three to five, or six or more weeks); the student’s perception of the time spent in these rotations and an index of his or her perception of the adequacy of time spent in instruction on ten selected didactic courses most relevant to public health dentistry; and cultural awareness and competency (vide infra). We summed the scores for each of the ten items on the student’s perception of the amount of time devoted (excessive, appropriate, or inadequate) to instruction in behavioral sciences, dental public health, oral epidemiology, organization and financing of health services, cultural competency, dental health policy, social and behavioral determinants of health, community dentistry, gender-related issues, and ethics. Responses were coded as follows: "excessive" was given a score of +1, "appropriate" was scored as 0, and "inadequate" was given a score of –1. Scores ranged from –10 to +10. A lower score therefore indicates that the students felt that the time devoted to instruction was inadequate.

Data analysis was carried out using Stata/SE Version 8.2. 7 The unit of analysis was a graduating senior student who reported spending at least one week in an extramural clinical rotation (n=2950). Students who reported no time in extramural rotations were excluded from the analysis (n=500). There was an extremely small percent of cases with data missing on any variable, and they did not affect the final sample size. For example, a mere 1.8 percent of cases had missing data on the "instruction" variable, and these were dropped from the analysis.

Since each dependent variable is binary in nature, logistic regression models were used to estimate the parameters specified in the behavioral model. To control for school level fixed effects, we included school dummy variables in the regression. The overall fit of the model to the data was assessed with the Hosmer-Lemeshow goodness of fit test. Multicollinearity and interaction effects were evaluated for the model.

	Results

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

 
Descriptive Analyses
Descriptive characteristics of the sample are shown in Table 1. Scores on the "service orientation" scale ranged from 3 to 15, with a mean of 9.9 and standard deviation of 2.6. Cronbach’s alpha for this scale was 0.62, indicating an acceptable level of reliability. Scores on the "socially conscious attitudes" scale ranged from 4 to 16, with a mean of 11.8 and standard deviation of 2.4. The Cronbach’s alpha for this four-item scale was 0.81, indicating a high degree of reliability.

Among the individual characteristics, only two variables were significant predictors. Native Americans, Blacks, and Hispanics, who were analyzed as a group, were more likely to characterize the extramural clinical rotations as a positive experience, as were students who ranked in the higher quartiles of the socially conscious attitude scale (Table 3). All the school level process variables were significantly associated with the student experience. Students who reported spending one to two weeks were significantly less likely to characterize the extramural rotation as a positive experience than those with three-to-five week rotations. Students who reported that the didactic instruction provided at the dental school devoted to cultural competency instruction was inadequate were more likely to report the extramural rotation being a positive experience.

	Multivariate Analyses

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

	Discussion

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

 
Although there are limitations to the ADEA survey due to differences in response rates from schools and the manner and time of year at which the student actually completed the survey, this remains the only comprehensive survey completed by all senior students in U.S. dental schools. With a response rate of 80 percent in 2002 and 83.2 percent in 2003, it remains a key instrument in understanding students’ dental school experience.^6,8

This analysis was designed to present a baseline analysis of student perceptions of the value of extramural rotations, at the outset of a major demonstration program targeted at increasing extramural rotations to at least sixty working days in the senior year—over one quarter of the senior year. This is a marked departure for dental education, one that could have a profound impact on the educational experience for dental students. Thus, it is appropriate to establish baseline findings against which comparisons can be made during the course of the demonstration.

The baseline model proposes that student perceptions could result from a combination of students’ background and their school experience. Student background characteristics included age, sex, race, marital status, and educational debt, as a proxy for student income. Two scales were constructed to measure students’ attitudes about the dental profession’s social contract with the community. These measures were developed to assess future changes among dental students during the course of the RWJF/TCE demonstration program. The first scale assessed students’ altruistic or service-oriented reasons for seeking dentistry as a career; the second scale measured their socially conscious attitudes about the importance of ensuring access to oral health care to all. Both scales reached acceptable levels of reliability, as measured by the Cronbach’s alpha score.

Being Asian or Pacific Islander, having a weaker socially conscious attitude, and having only one to two weeks’ experience in a rotation were determinants of a more negative perception of the rotation. Since many community clinics were established in areas with historically underserved Black and Hispanic patients, schools may want to assess why Asian and Pacific Islanders rated the rotations less positively than other students. Just as research shows that patients self-select doctors who are similar to them, perhaps students in a learning mode react more positively to serving patients of a similar culture. If so, it will be important for schools to provide extramural rotations for a wider variety of patient populations served.^9,10 A definitive answer to this question is beyond the capability of the ADEA survey. Moreover, while a service-oriented reason for selecting dentistry was not significant in the multivariate model, one’s positive attitude toward access to oral health care and spending more than two weeks were significant determinants after controlling for other factors.

Regarding the second dependent variable—the perception that extramural rotations positively increased one’s ability to provide care to people who were different from them—no race/ethnicity group differences were found, but both constructed scales (the service orientation scale and the socially conscious attitude) were significant determinants of a positive perception. Further, the strength of the odds ratio for the time spent in rotation suggested that increased time could improve one’s ability to provide care to diverse patient populations.

It is important to note that student perception about the extramural rotations could also be based on factors such as the degree of independence at these rotations, the number and types of procedures performed at the site(s), the ability to work with assistants, etc. These aspects are not ascertained by the ADEA survey, and further research is needed to quantify their impact. In addition, several research questions arise regarding the two scales reported here. First, could the question asked about reasons for selecting dentistry as a profession, with its component orientation toward service, actually predict students (and future dentists) with stronger service mentality? These items were asked anonymously at the conclusion, not the initiation, of dental school, so they included three to four years of socialization in dental school. Finding a valid scale that could predict service would be an intriguing asset to the dental profession, at least for dental schools with a mission of service. Second, are there specific courses within the dental school curriculum that could positively impact students’ learning about the importance of access to oral health care that would help to decrease the disparities in oral health noted in the U.S. Surgeon General’s report on oral health? Our current index that measures students’ perception of curricular time for various topics was not a significant determinant of either dependent variable. Perhaps alterations to the curriculum, as proposed in the RWJF/TCE demonstration, may help to answer this question.

The most important finding from this study was that a school’s involvement in the RWJF/TCE demonstration program was significantly associated with both of the dependent variables that we selected as future outcome measures. There are two possible explanations for this finding. While there could have been a selection effect at the national level, the California schools joined the program a year later, making a diffusion effect plausible. The dental school experience exerts a profound impact as the student is socialized in the profession of dentistry. A large source of funding during the time a student is in dental school may generate excitement among faculty and students about extramural rotations and the value of service to the community. All schools conveyed a positive enthusiasm about the challenge of increasing the time students spend in clinical rotations. It will be important to watch how the demonstration unfolds and whether students’ perceptions change to reflect this.

	Acknowledgments

 
We would like to acknowledge the assistance of Dr. Richard Weaver and the American Dental Education Association in collaborating in the modification of the Senior Survey, and for Dr. Weaver’s guidance in the process. We also acknowledge the entire National Evaluation Team, Drs. Pamela Davidson, James Freed, Judith Ann Friedman, Edmond Hewlett, Mr. John Gutierrez, and Mr. Terry Nakazano for their contributions and assistance on the overall project. We acknowledge also the support from The Robert Wood Johnson Foundation Grant #045592 and The California Endowment Grant #20031951.

	REFERENCES

Top Abstract Materials and Methods Results Multivariate analyses Discussion References

 

1. Ayers CS, Abrams R, Robinson M. U.S. and Canadian dental school involvement in extramural programming. J Dent Educ 2001;65(11):1272–7.[Abstract]
2. DeCastro JE, Matheson PB, Panagakos FS, Stewart DC, Feldman CA. Alumni perspectives on community-based and traditional curricula. J Dent Educ 2003;67(4):418–26.[Abstract]
3. Butters JM, Vaught RL. The effect of an extramural education program on the perceived clinical competence of dental hygiene students. J Dent Educ 1999;63(5):415–20.[Abstract]
4. Grantham EV, Block MJ. Effect of extramural experiences on dental students’ attitudes. J Dent Educ 1983;47(10): 681–4.[Abstract]
5. Gardiner JF, Lotzkar S. A survey of extramural experiences for dental students. J Dent Educ 1975;39(8):530–4.[Abstract]
6. Weaver RG, Haden NK, Valachovic RW. Annual ADEA survey of dental school seniors: 2002 graduating class. J Dent Educ 2002;66(12):1388–404.[Medline]
7. StataCorp. Stata Statistical Software Release 8.2. College Station, TX, 2004.
8. Weaver RG. Personal communication, June 2003.
9. Gray B, Stoddard JJ. Patient-physician pairing: does racial and ethnic congruity influence selection of a regular physician? J Community Health 1997;22(4):247–59.[Medline]
10. Gerbert B, Berg-Smith S, Mancuso M, et al. Video study of physician selection: preferences in the face of diversity. J Fam Pract 2003;52(7):552–9.[Medline]

This article has been cited by other articles:

				E. S. Pilcher, L. T. Charles, and C. J. Lancaster Development and Assessment of a Cultural Competency Curriculum J Dent Educ., September 1, 2008; 72(9): 1020 - 1028. [Abstract] [Full Text] [PDF]

				S. Thikkurissy, M. L. Rowland, C. Y. Bean, A. Kumar, K. Levings, and P. S. Casamassimo Rethinking the Role of Community-Based Clinical Education in Pediatric Dentistry J Dent Educ., June 1, 2008; 72(6): 662 - 668. [Abstract] [Full Text] [PDF]

				K. FitzGerald, N. S. Seale, C. A. Kerins, R. McElvaney, and E. Fitzgerald The Critical Incident Technique and Pediatric Dentistry: A Worked Example J Dent Educ., March 1, 2008; 72(3): 305 - 316. [Abstract] [Full Text] [PDF]

				B. R. Johnson, P. M. Loomer, S. C. Siegel, E. S. Pilcher, J. E. Leigh, M. J. Gillespie, R. K. Simmons, and S. P. Turner Strategic partnerships between academic dental institutions and communities: Addressing disparities in oral health care J Am Dent Assoc, October 1, 2007; 138(10): 1366 - 1371. [Abstract] [Full Text] [PDF]

				E. R. Hewlett, P. L. Davidson, T. T. Nakazono, S. E. Baumeister, D. C. Carreon, and J. R. Freed Effect of School Environment on Dental Students' Perceptions of Cultural Competency Curricula and Preparedness to Care for Diverse Populations J Dent Educ., June 1, 2007; 71(6): 810 - 818. [Abstract] [Full Text] [PDF]

				R. A. Kuthy, K. E. Heller, K. J. Riniker, M. R. McQuistan, and F. Qian Students' Opinions About Treating Vulnerable Populations Immediately After Completing Community-Based Clinical Experiences J Dent Educ., May 1, 2007; 71(5): 646 - 654. [Abstract] [Full Text] [PDF]

				A. K. Mascarenhas, S. R. Freilich, M. M. Henshaw, J. A. Jones, M. L. Mann, and S. N. Frankl Evaluating Externship Programs: Impact of Program Length on Clinical Productivity J Dent Educ., April 1, 2007; 71(4): 516 - 523. [Abstract] [Full Text] [PDF]

				P. L. Davidson, D. C. Carreon, S. E. Baumeister, T. T. Nakazono, J. J. Gutierrez, A. A. Afifi, and R. M. Andersen Influence of Contextual Environment and Community-Based Dental Education on Practice Plans of Graduating Seniors J Dent Educ., March 1, 2007; 71(3): 403 - 418. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Thind, A. Articles by Andersen, R. Search for Related Content PubMed PubMed Citation Articles by Thind, A. Articles by Andersen, R.