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J Dent Educ. 71(8): 1020-1026 2007
© 2007 American Dental Education Association
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Critical Issues in Dental Education

Comparing Fourth-Year Dental Student Productivity and Experiences in a Dental School with Community-Based Clinical Education

Canise Y. Bean, D.M.D., M.P.H.; Michael L. Rowland, Ph.D.; Hilary Soller, D.D.S.; Paul Casamassimo, D.D.S., M.S.; Rachel Van Sickle, B.S.; Kevin Levings, B.A.; Rachel Agunga

Key words: dental education, service-learning, community-based, productivity

Submitted for publication 01/18/07; accepted 04/06/07


   Abstract
Top
 Abstract
Methodology
 Results
 Discussion
 Conclusions
 References
 
Reports and articles by the Institute of Medicine, the American Dental Education Association (ADEA) Commission on Change and Innovation in Dental Education (CCI), and the Macy Foundation have examined the challenges confronting dental education and reached the conclusion that U.S. dental education is on the brink of major change. A recent "case for change" article by the CCI makes the argument that dental education, as currently structured, is quickly becoming obsolete, overpriced, and lacking in its ability to provide the education that future practitioners will need. The Ohio State University College of Dentistry (OSUCOD) began a major reorganization of its clinical education program upon receipt of a Robert Wood Johnson Foundation-sponsored Pipeline, Profession, and Practice grant. In our fourth year of the five-year grant program, known as the OHIO Project (Oral Health Improvement through Outreach), our fourth-year dental students approached the sixty-day target of time spent in community-based clinical education. The purpose of this report is to describe the productivity of students and the characteristics of the patient pool they care for in community-based sites as compared to our school-based clinics during that final year. This report reflects the activity of 102 students in the graduating class of 2006. Attendance (clinic utilization) was estimated to be 94 percent at OSUCOD and 99 percent at OHIO Project sites. In the aggregate, the OHIO Project-based students treated a total of 11,808 unique patients and completed 26,882 procedures in the community during their 41.9-day community experience. This translates into 116 unduplicated patients and 264 procedures per student in the community-based sites for the period studied. In comparison, the same students treated 19,344 unique patients and completed 28,680 procedures during ninety-three clinic days at the school. Each student treated 190 patients and completed 281 procedures. Fourth-year dental students completed as many procedures and generated similar revenue-equivalents in community sites as they did in a dental school clinic in half the time.

U.S. dental schools are on the brink of major change. Dental schools in the United States are under increasing pressure to change their clinical delivery systems. Pyle et al. point to three major issues that dental education must address: 1) lack of adequate funding for dental programs, which are costly for universities to operate; 2) lack of vision to provide care for those with limited access and financial means; and 3) a dental curriculum that is not flexible or student-friendly. Other issues include a shortage of qualified faculty, lower faculty salaries compared to private practice, quality of work-life, and a workforce lacking in diversity, possibly because of the cost of dental education.1 The Institute of Medicine (IOM),2 the American Dental Education Association (ADEA) Commission on Change and Innovation in Dental Education (CCI),3 and the Macy Study4 have independently examined the challenges confronting dental education, explored the opportunities for change, and reached similar conclusions.

Leadership for change has also come from outside of the dental profession. The Robert Wood Johnson (RWJ) Foundation and The California Endowment have established grants to dental schools designed to 1) provide opportunities for senior dental students to spend sixty days in community settings to develop skills for treating underserved populations as culturally competent dentists in a multicultural world, and 2) recruit more low-income and underrepresented minorities to the dental profession. In 2004, the Josiah Macy, Jr. Foundation provided funding to the Center for Community Health Partnerships at Columbia University to study the key financial and educational issues facing dental education and to develop new strategies and models of financing and delivering dental education.4

To address the need to make oral health care accessible to marginalized groups (i.e., poor, low-income, racial and ethnic minorities), traditional dental schools have looked to community-based educational experiences. Several studies have examined the role of community-based education compared to traditional dental school-based clinics. DeCastro et al. asked whether community-based sites provide the same level of teaching and learning as the dental school5 and concluded that community-based sites can be as effective. Christie et al. studied a community site clinic in a case study and developed a model that is heavily based on extramural clinics.6 Skelton et al. provided a description of a community-based program at the University of Kentucky and reported an increase in knowledge for the majority of students.7 Cinotti et al. described a plan to incorporate community-based education that includes a variety of funding streams to support it and provide dental students with extramural experiences.8

The Ohio State University College of Dentistry began a major reorganization of its clinical education program upon receipt of an RWJ Foundation-sponsored Pipeline, Profession, and Practice grant. In the fourth year of the five-year grant program, known as the OHIO Project (Oral Health Improvement through Outreach), the fourth-year dental students averaged forty-two days in community-based dental care settings, which approached the sixty-day RWJ target for number of days each student spends in community-based clinical education. The purpose of this report is to describe the productivity of students and the demographic and socioeconomic characteristics of the patient pool they treated in community-based sites compared to our school-based clinics.


   Methodology
Top
 Abstract
 Methodology
Results
 Discussion
 Conclusions
 References
 
This report reflects the activity of 102 students in the graduating class of 2006. This class was prospectively required to spend forty-two days in assigned community-based placements and could self-select sites to account for another 4.5 days, thus totaling 46.4 days during their fourth year, which approaches the RWJ target of sixty days of community service. When not assigned to community sites, students treated their patient pool in the school clinics at the Ohio State University College of Dentistry (OSUCOD). Students in both settings were required to track daily productivity for educational credit and patient billing.

The Pipeline program instituted a methodology for data collection that would be common to and consistent across all grantee schools. This was done because of the recognition that each school already had its own method of data collection for billing and student performance and compatibility of the various systems was unlikely. At OSUCOD, there has been a data collection process in place and a processing system (Windent®) that has demographic and dental code variables consistent with the Pipeline program data collection process. These variables have been used in this comparison.

Data for the community sites were student- reported following treatment completion and returned to the OHIO Project staff for data entry. OSUCOD data were recorded by the student and entered into the college’s computerized clinic information management system (Windent) by clinic staff using a system of checks and balances to verify input accuracy. Time in clinic at OSUCOD is also student-reported, verified by staff, and entered into the system, allowing a calculation of percentage utilization based upon the number of times a student is expected and the actual number of half days present or legitimately accounted for, such as doing required laboratory work. The off-site data collection is highly student-dependent and not needed or used by most sites for management or billing. We estimated a 9 percent chance of error due to nonreporting for community sites, and reported totals for community sites may be less than actually performed. The estimate was determined by comparing known schedules and productivity for sites with other quarters’ performance. Pediatric patients in this report are identified as sixteen years of age and younger. Visit type was determined to be regular (non-pain-related appointment), emergency (pain-related), or screening (such as a Head Start or Health Fair screening; not a screening appointment in the facility). We assigned our OSUCOD clinic fee schedule to procedures done at both sites to compare revenue generated, simply for purposes of comparison using a consistent fee per procedure. In reality, both fees and payments vary greatly across sites.

Data from the community sites were entered using a Microsoft Excel program developed and provided to all the Pipeline schools. For the purposes of this study, reports were generated from this database to mirror those reflected in Windent for the procedures done at OSUCOD for the purposes of this report. Simple calculations were performed to determine means, totals, and distributions reported.


   Results
Top
 Abstract
 Methodology
 Results
Discussion
 Conclusions
 References
 
For the period June 5, 2005, through June 4, 2006, 102 fourth-year dental students spent an average of forty-two days treating patients in nineteen community-based OHIO Project (OP) sites. Alternatively, they averaged ninety-three days in the College of Dentistry school-based clinics, thus spending slightly more than twice the amount of time in the school clinics as they did at community sites.

Attendance (clinic utilization) at OSUCOD was 94 percent, while at the OP sites, it was estimated to be 99 percent. OHIO Project-based students treated a total of 11,808 patients and performed 26,882 procedures in the community. This translates to 116 unduplicated patients and 264 procedures per student in the community-based sites for the period studied. The data are depicted in Table 1Go.


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  		Table 1. Student encounters and performance in the OHIO Project (OP) and school-based clinics (OSUCOD) for the study year, June 2005 through June 2006
 
Table 2Go compares the OP and OSUCOD experiences related to selected demographic variables. Gender distributions were quite similar for both programs, but more minority patients were seen in the community-based clinics compared to the school-based clinics. The distribution of African Americans is high in the OP sites and low in the OSUCOD clinics, compared to Ohio’s population, which is 12 percent by the most recent census data.9


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  		Table 2. Patient demographic variables for OHIO Project and school-based clinics
 
There was a disproportionate percentage of adults in the school-based clinics compared to the community clinics. This is likely due to the small number of hours devoted to pediatric oral health in the Ohio State curriculum and the fact that children are treated in a pediatric specialty clinic at the school.

Payment mechanisms differ greatly between the two programs, with school-based patients having a greater ability to pay, with either insurance or cash. The community-based sites offer care to a lower- income population, with few privately insured patients receiving care in these sites. Most community sites offer sliding fee scales based on a patient’s ability to pay for services. The OSUCOD currently does not offer this option to clinic patients.

Finally, the distribution of treatment procedures indicates that both programs offer primarily comprehensive care opportunities for students, in spite of the payment mechanisms predominant at both sites.

Decisions regarding the future of the community-based educational program of the OHIO Project hinge on a variety of factors, including cost, student acceptance, continued community acceptance, and value to the overall educational program. This latter point involves the relative contribution of community-based experiences to student learning in terms of diversity, quality, and quantity of experiences. We were interested in comparing the types and numbers of procedures done by students in the two programs as well as how both programs compared with what students might do in private practice. Table 3Go compares the twenty-five most commonly performed procedures in the two programs. It also includes the top twenty-five procedures for which claims were filed from a large private dental insurer doing business in Ohio (Delta Dental). These data were used to reflect the types of dental procedures most commonly performed in private dental practices. Of interest is the fact that the students’ community-based experience provided them with six of the ten most frequently performed OSUCOD clinic procedures (highlighted in table), and overall, the OHIO Project experience provided students with the opportunity to perform fourteen of the most frequent twenty-five procedures done at the school clinics.


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  		Table 3. Comparison of school-based clinic and OHIO Project’s twenty-five most common procedures with Ohio Medicaid and Delta Dental Ohio claims
 
Table 3Go includes data from Delta Dental Corporation for its Ohio claims. Delta Dental covers more Ohioans treated by dentists in private practice than any other insurer. Only three of Delta’s ten most frequent procedures are in the OSUCOD clinics’ ten most frequent, while six of the OHIO Project’s ten are. However, when all twenty-five of Delta’s procedures are cross-referenced with those of both school programs, the OHIO Project includes seventeen and the OSUCOD clinics sixteen matching procedures, suggesting good concordance with private practice patterns at both sites.


   Discussion
Top
 Abstract
 Methodology
 Results
 Discussion
Conclusions
 References
 
The genesis of this analysis and report was The Ohio State University College of Dentistry’s five-year experience in community-based education prompted by an award from the RWJ Foundation Pipeline program. The study year presented was the first full year of operation of the OHIO Project in terms of student time out of school, and thus the first opportunity to compare student experiences within the College of Dentistry with those performed in community settings. Overall, the findings show that students in the community, working under the tutelage of adjunct faculty, perform more procedures more efficiently than they do in the OSUCOD school-based clinics. It is beyond the scope of this report to answer questions about comparative quality, supervision, and the relative educational value of the community-based component of our students’ experiences. In subsequent publications, we hope to demonstrate not only student receptiveness to the community-based experience, but positive outcomes, some unintended, for the college-based predoctoral clinical education program, such as increased productivity and lower absenteeism.

In this era of competency-based education, there is continuing debate about the frequency and quality of clinical experiences needed to determine student competency. In this analysis, we were surprised to find that dental students were twice as productive in the community as they were in the OSUCOD clinics: essentially, students accomplished twice as many procedures in the community in less than half the time. Traditional school-based clinics remain vital for exposing students to certain treatment modalities, but community-based sites offered students more experiences with more patients. At the community sites, students averaged 116 patients in forty-two days, approximately three patients per day, while at the school clinics, students averaged 190 patients in ninety-three days, or two patients per day. This expanded level of contact with patients offered students additional opportunities to see complex and cultural interactions now known to influence health care seeking practices and compliance. Our community-based experience not only seems to provide a more efficient way to educate predoctoral students from the perspective of procedures and patients per unit time, but also an opportunity to capitalize on a broader and more diverse patient profile with realistic constellations of oral and other problems.

One objective of the Pipeline program is to expose dental students to a broader diversity of patients within their four-year education. Data suggest that the community clinics provided students more exposure to patients of varied ethnicity as compared to the OSUCOD school clinics. One limitation of our analysis is that the OSUCOD clinics do not consistently record some demographic variables, resulting in a large amount of missing information. If we make the assumption that missing college data are spread evenly across the ethnic and racial categories, then it appears that students in the community see a more heterogeneous patient pool, including regarding method of payment. Ironically, the OHIO Project patient pool may be more representative of Ohio’s citizenry than those seen at the school clinics since the minority populations are higher in the state than what is seen in the school clinics.

An equally important goal of the OHIO Project is to assess the benefit of service-learning at community sites as a way to address problems common to all of dental education: aging physical plant, changing patient base, diminishing faculty, reduced state support, and rising costs, to name a few.4 The community-based sites provide several educational and financial opportunities. The OHIO Project team was pleased to see that students were very productive off campus, but also noted that they performed many of the same procedures as in OSUCOD clinics (Table 3Go). Several more complex and expensive procedures, such as crowns and dentures, were not performed as frequently in the community, largely due to the patient pool and short length of rotations. Both the duplication and the variation of procedures offer opportunities to change curriculum and possibly refocus the teaching emphasis and increase revenue for the dental school by devoting more time to more complex procedures under closer scrutiny of faculty, who may now be spending time overseeing simple procedures that could be done in the community.

The fiscal analysis completed has numerous shortcomings, but provides a window to other opportunities for the educational process. The diversity of community sites and their very different fee schedules made it almost impossible to assign a true value to the procedures performed by our students off campus, so we assigned our OSUCOD clinic fee schedule to equalize the revenues for discussion purposes. Based on this, students provide about twice the service (in dollars) in the community as they do on campus (Table 1Go). This may be a result of more efficient care delivery, including four-handed dentistry, the less complex nature of the community-based procedures, less bureaucracy, or a better supervisory ratio off campus. One might ask whether losing this revenue is wise for a dental school, but a more astute observation would be that a dental school might learn from these sites and incorporate some of their practices into the school-based clinics to enhance clinic income. In addition, as community sites benefit from increased income due to unpaid dental student providers, they can be approached to compensate a dental school.

Finally, at some point, student absence from the dental school should yield a reduction in faculty, staff, supply cost, and maintenance. For our state-funded dental school, the contribution to Ohio’s citizens can’t be overlooked as the OHIO Project team seeks improved funding for our programs.


   Conclusions
Top
 Abstract
 Methodology
 Results
 Discussion
 Conclusions
References
 
Senior students at The Ohio State University College of Dentistry were more productive in off-site community-based clinics and had opportunities to provide patient care for a more diverse patient population than they encounter at the dental school clinic. In addition, the OHIO Project has created other outcomes few of us expected. Anecdotal feedback from our students and faculty is that students come back to school-based clinics more confident and skilled. Attendance in school-based clinics is better since the onset of the OHIO Project, perhaps because students recognize they need to complete their school-based requirements in fewer available days. Clinic revenue has increased as has the number of procedures performed per student at the OSUCOD over the last five years. Community good will is high, with more clinics seeking students to provide services in their communities than the OSUCOD can provide. Our community adjunct faculty have told us that they enjoy interacting with and providing education for students and report that they feel good about the treatment provided by students as well as their contribution to the oral health of their patients.


   Acknowledgments
 
The authors thank Delta Dental Service of Ohio and Michigan for sharing data for comparison in this report.


   Footnotes
 
Dr. Bean is Associate Professor-Clinical, Section of Restorative and Prosthetic Dentistry; Dr. Rowland is Assistant Professor, Section of Primary Care; Dr. Soller is Associate Professor-Clinical, Section of Primary Care; Dr. Casamassimo is Professor and Section Head of Pediatric Dentistry; Ms. Van Sickle is a member of the OHIO Project Staff; Mr. Levings is a member of the OHIO Project Staff; and Ms. Agunga is a Summer Research Student—all at The Ohio State University College of Dentistry. Direct correspondence and requests for reprints to Dr. Michael Rowland, Section of Primary Care, College of Dentistry, Room 3166 Postle Hall, 305 West 12th Avenue, Columbus, OH 43218; 614-247-8621 phone; 614-247-6599 fax; Rowland.3{at}osu.edu.


   REFERENCES
Top
 Abstract
 Methodology
 Results
 Discussion
 Conclusions
 References
 

  1. Pyle M, Andrieu SC, Chadwick G, Chmar JE, Cole JR, George MC, et al. The case for change in dental education. J Dent Educ 2006; 70(9):921–4.[Abstract/Free Full Text]
  2. Field MJ, ed. Dental education at the crossroads: challenges and change. Institute of Medicine Report. Washington, DC: National Academy Press, 1995.
  3. American Dental Education Association. What is the ADEA Commission on Change and Innovation in Dental Education: how did it get started? Bull of Dent Educ 2005;38(12).
  4. Formicola AJ, Bailit H, Beazoglou T, Tedesco LA. The Macy study: a framework for consensus. J Dent Educ 2005; 69(11):1183–5.[Free Full Text]
  5. DeCastro JE, Bolger D, Feldman CA. Clinical competence of graduates of community-based and traditional curricula. J Dent Educ 2005; 69(12):1324–31.[Abstract/Free Full Text]
  6. Christie D, Maida CA, Freed JR, Marcus M. Identifying and responding to competing needs: a case study of a dental school-operated community dental clinic. J Dent Educ 2003; 67(11):1243–51.[Abstract]
  7. Skelton J, Mullins MR, Kaplan AL, West KP, Smith TA. University of Kentucky community-based field experience: program description. J Dent Educ 2001; 65(11):1238–42.[Abstract]
  8. Cinotti WR, Saporito RA, Feldman CA, Mardirossian G, De Castro J. Community-based dental programs: University of Medicine and Dentistry of New Jersey-New Jersey Dental School. J Dent Educ 1999; 63(12):969–75.[Abstract]
  9. U.S. Census 2000. At: www.census.gov/census2000/states/oh.html. Accessed: January 17, 2007.



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