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J Dent Educ. 72(12): 1472-1480 2008
© 2008 American Dental Education Association
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Critical Issues in Dental Education

Reforming Dental Education: Faculty Members’ Perceptions on the Continuation of Pipeline Program Changes

Amardeep Thind, M.D., Ph.D.; Kathryn A. Atchison, D.D.S., M.P.H.; Ronald M. Andersen, Ph.D.; Terry T. Nakazono, M.A.; John J. Gutierrez, B.A.

Key words: pipeline program, extramural rotations, URM/LI recruitment, faculty perceptions

Submitted for publication 05/02/08; accepted 09/08/08


   Abstract
Top
 Author information
 Abstract
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
In 2002–03 the Robert Wood Johnson Foundation (RWJF) established the Pipeline, Profession, and Practice: Community-Based Dental Education program to change dental education in the United States. In partnership with The California Endowment, the RWJF awarded grants to fifteen U.S. dental schools that would support them in efforts to recruit more underrepresented minority/low-income (URM/LI) students, add cultural competence training, and increase extramural rotations to sixty days. As the program evaluator, the University of California, Los Angeles, School of Public Health (UCLA-SPH) conducted a survey of dental faculty in 2006 related to the goals of the Pipeline program. In this article, we report faculty perceptions pertaining to the extramural rotations and URM/LI recruitment. The survey was conducted in fourteen U.S. dental schools that received Pipeline grants and had an overall response rate of 60 percent (n=1,027) from the 1,713 faculty members who received the survey. A majority (57 percent) of faculty members strongly agreed that extramural rotations should continue as an integral part of students’ education; 51 percent felt the same about the continuation of URM/LI recruitment programs. Multivariate logistic regression analyses revealed that faculty type, perception of extramural rotations being a positive experience, increased student productivity, and school culture were significant determinants of support for continuation of the extramural rotation programs. Determinants of support for continuation of the URM/LI recruitment programs were faculty type, perception of URM/LI recruitment effectiveness, perception of students from diverse backgrounds improving educational experience, and having a school mission statement that supports URM/LI recruitment. Pipeline schools should ensure that their extramural faculty remain key players in the Pipeline programs, widely publicize the programs’ successes, and develop a service-oriented culture in order to build and sustain faculty perceptions that these programs should continue as integral parts of the schools’ educational mission.

In 2002–03 the Robert Wood Johnson Foundation (RWJF) launched the Pipeline, Profession, and Practice: Community-Based Dental Education program with the aim of changing dental education in the United States.1 Eleven dental schools were competitively selected to receive five-year grants that would help them to recruit more under-represented minority and low-income (URM/LI) students, introduce additional cultural competence training in their curricula, and increase students’ extramural rotations in community sites to sixty days. A year later, The California Endowment (TCE) funded four additional California dental schools (the University of California, San Francisco, was originally funded by the RWJF) to undertake similar curricular changes.

The focus on increasing URM/LI student recruitment and supporting curricular change was based on well-documented evidence of need. The demographic character of the United States is changing, with nonwhites becoming an ever-larger proportion of the population.2 However, this shift is not mirrored in either the student body entering dental schools or in the dental provider community.3 More than a decade ago, a report from the Institute of Medicine called for a dental workforce that is representative of the nation’s ethnic makeup.4 Although Hispanics and African Americans each comprise approximately 10 percent of the U.S. population, each group accounts for only 3.3 percent of dentists.5 This disparity has potential negative consequences for minorities, as evidence suggests that they experience greater need for, and encounter greater barriers to accessing, oral health care.6–8 Eliminating this disparity would improve access to care since the literature suggests that minority dentists are a significant source of care for minority patients.9

Extramural rotations, another important part of the Pipeline program, are a mechanism for exposing dental students to underserved populations they would not encounter within the main school clinics.10,11 Research evidence suggests that senior students who have spent time in such community clinic rotations were significantly more likely to be confident and prepared to enter the dental profession.12

By the end of the five-year Pipeline grant period, all the schools involved had instituted programs that made significant progress in meeting the three goals of the Pipeline program.13,14 The University of California, Los Angeles (UCLA) School of Public Health was chosen as the national evaluator of the Pipeline program, as previously reported in this journal,15 and, as part of its mandate, conducted a survey of all faculty members of the participating schools in 2006. Among other questions, the survey inquired about faculty members’ perceptions of the changes made at their respective schools as part of the Pipeline program. In this article, we report on the perceptions of faculty at Pipeline dental schools pertaining to the extramural rotations and URM/LI student recruitment.


   Materials and Methods
Top
 Author information
 Abstract
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Our data source was the 2006 Pipeline faculty survey, in which fourteen out of the fifteen Pipeline schools participated. The goal of the survey instrument was to capture faculty perceptions related to the Pipeline program. The survey was administered to all dental school faculty members in these categories: those holding 40 percent or greater time appointments, basic science course chairs, and community dentists who had supervised one or more students in the past two years. Questions focused on extramural rotations, overall quality of care, recruitment programs and their effectiveness, and barriers to sustainability. Out of 1,713 surveys administered, 1,027 were returned, which is a 60 percent response rate.

Two dependent variables were constructed. The survey asked faculty members to indicate their agreement/disagreement with the following statements: "extramural clinical rotations should continue as an integral part of the students’ clinical education" and "recruitment of URM/LI students should continue as an integral part of the dental school’s mission." Responses were on a scale from 1 (strongly disagree) to 4 (strongly agree). Due to the skewed nature of the responses, we dichotomized the variables into "strongly agree" (category 4) and "not strongly agree" (categories 1, 2, and 3).

For independent variables, we posited that faculty members’ perceptions regarding the continuation of the extramural rotations were a function of individual and contextual level factors. Individual level factors were the following: 1) gender; 2) race/ethnicity (URM, Asian/Pacific Islander, white, prefer not to specify); 3) faculty type (full-time intramural instructor, part-time intramural instructor, extramural instructor); 4) perception whether extramural rotations are a positive or negative experiences in a student’s education (coded as very positive, not very positive, don’t know); 5) productivity of students in extramural rotations (much more, more/less, and don’t know); and 6) whether the respondent feels that the school has a culture that emphasizes serving the community and promoting access to dental care (strongly agree/agree, neutral/disagree/strongly disagree). Regarding the fourth factor, response categories to the question "Are extramural clinical rotations in community settings positive or negative experiences in students’ education?" were very negative, negative, neutral, positive, very positive, and don’t know/not familiar with the program. Due to the skewed nature of the responses—56 percent (n=502) replied "very positive" and 36 percent (n=325) replied "positive"—we decided to trichotomize the responses to very positive, not very positive (including the response categories positive, neutral, negative, and very negative), and don’t know. Regarding the fifth factor, response categories to the question "Are senior students more or less clinically productive in extramural clinical rotations than in the main school clinics?" were much less, less, same, more, much more, and don’t know/not familiar with the program. Due to the skewed nature of the responses—29 percent (n=220) replied "much more" and 52 percent (n=390) replied "more"—we decided to trichotomize the responses to much more, more/less (including the response categories more, same, less, and much less), and don’t know.

Contextual factors were created using a variety of data sources. The type of school (publicly funded or privately funded) was based on data from the American Dental Association (ADA). Pipeline status (RWJF or TCE awardee) was derived from the National Program Office that coordinates the Pipeline program. Using data available on each school’s website, a variable capturing whether the school has a mission statement committing it to serve the URM population (yes, no) was created. The percentage of the population below 200 percent of the federal poverty level in the county where the school is located was based on the 2000 U.S. census. Further details regarding the construction of these variables are available elsewhere.16

Individual level factors for the model predicting perceptions regarding the continuation of increased URM/LI recruitment were gender, race/ethnicity, faculty type (coded as above), effectiveness of the URM/LI recruitment program (good/excellent, poor/fair, don’t know), and the perception that having students from diverse backgrounds improves the educational experience (strongly agree, not strongly agree, don’t know). Contextual factors were type of school and Pipeline status (both coded as above), a binary variable capturing whether the school has a mission statement committing itself to URM/LI recruitment, percent URM population in the county, percent URM faculty in the school, and percent URM students in the school. These contextual variables were created using the data sources enumerated above.

Data analyses were carried out using Stata 10.2.17 The unit of analysis was an individual faculty member (n=1,027). Missing data were not a problem except for two variables: gender and race/ethnicity. Nonrespondents to both these questions were coded as "prefer not to specify" and were included in the analyses: 13.8 percent (n=135) preferred not to specify their gender, while 17.4 percent (n=170) preferred not to specify their race/ethnicity. Unadjusted odds ratios were calculated to evaluate the relationship between the dependent and independent variables. Adjusted odds ratios were obtained by performing logistic regression analyses, which included all the independent variables in the model. Overall goodness of fit of the logistic regression model was assessed using the Hosmer-Lemeshow test.


   Results
Top
 Author information
 Abstract
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
In our sample, 57 percent of the respondents strongly agreed that extramural rotations should continue as an integral part of the students’ clinical education; only a slight majority (51 percent) had the same sentiment towards the continuation of URM/LI recruitment (Table 1Go). Our sample was predominantly male (62 percent) and white (62 percent); full-time intramural instructors accounted for 60 percent of all respondents. Nearly half of the total respondents felt that extramural rotations were very positive experiences in students’ education, but only a fifth (22 percent) felt that students were much more productive during the rotations. A majority agreed that their school had a culture emphasizing community service and promoting access and that having students from different backgrounds improved the educational experience. While 43 percent felt that the effectiveness of their school’s URM/LI recruitment program was good/excellent, nearly a third (32 percent) responded that they didn’t know its effectiveness.


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  		Table 1. Descriptive characteristics of the faculty members surveyed and their perceptions regarding extramural rotations and URM/LI recruitment, by number and percentage of total responses
 
A large majority of schools did not have a mission statement espousing commitment to serve the URM population (77 percent) or to URM/LI recruitment (83 percent). The counties where the dental schools were located had a mean number of four federally qualified health centers (FQHC), and counties represented by the respondents had nearly a third of the population below 200 percent of the Federal Poverty Level (FPL). The mean percentage of URM dental students and URM faculty in the fourteen schools was 14 percent and 12 percent, respectively.

Extramural Rotations
Table 2Go presents the unadjusted and adjusted odds ratios for the association between the two dependent variables and individual and contextual independent variables. Unadjusted analyses show that male faculty members and those who did not specify their gender were less likely than female faculty members to strongly agree with the statement that extramural rotations should continue as an integral part of the students’ education. Asian/Pacific Islander faculty and those who did not specify their race/ethnicity were also less likely than URM faculty to agree with the statement, while extramural faculty members were more likely than full-time intramural instructors to strongly agree with the statement. Faculty perceptions that student productivity was higher and extramural rotations were a positive experience were both strongly associated with the perception that extramural rotations should continue as an integral component of the curriculum, as was a perception that the school has a culture emphasizing community service and promoting access. None of the contextual variables (type of school, Pipeline status, number of FQHCs in county, mission statement of serving URM population, or percent population in county below 200 percent FPL) were statistically significant in the unadjusted analyses.


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  		Table 2. Adjusted and unadjusted odds ratios of determinants of perception that . . .
 
In the adjusted analyses, after controlling for other variables, the following variables remained statistically significant: extramural instructor, extramural rotations are a positive experience, productivity of students in extramural rotations, and school culture emphasizing community service and promoting access.

URM/LI Recruitment
Unadjusted analyses revealed that male faculty members and those who did not specify their gender were less likely then female faculty members to agree strongly with the statement that URM/LI recruitment should continue as an integral part of the school’s mission. Compared to URM faculty, Asian/Pacific Islanders, whites, and those who did not specify their race/ethnicity were less likely to strongly agree with this statement. Compared to full-time intramural instructors, part-time instructors were less likely to strongly agree with the statement about URM/LI recruitment continuing as an integral part of the school’s mission; on the other hand, extramural instructors were more likely to strongly agree. Faculty members who didn’t know about the effectiveness of the URM/LI recruitment program were less likely to strongly agree, while those faculty members who felt that having students from different backgrounds improved the educational experience were more likely to agree to the need for continuation of the URM/LI recruitment program as an integral part of the school’s mission. Among contextual factors, faculty members from TCE schools were less likely to agree with the statement compared to faculty members from RWJF schools. Having a mission statement that commits the school to URM/LI recruitment and a greater percentage of URM faculty and students were associated with a greater likelihood of agreeing with the continuation of the URM/LI recruitment program as an integral part of the school’s mission.

In the adjusted analysis after controlling for other variables, gender, race/ethnicity, Pipeline status, percent URM faculty, and percent URM students became nonsignificant. Faculty type, perception of URM/LI program recruitment effectiveness, perception that students from diverse backgrounds improve the educational experience, and having URM/LI recruitment as a component of the school mission statement remained statistically significant, in a direction similar to the unadjusted analyses.


   Discussion
Top
 Author information
 Abstract
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Dental school faculty members are key standard bearers of change, and it is important to ascertain their perceptions of the process (and outcome) of this change. Faculty support can make the difference between the success or failure of a proposed program. Multiple articles in recent issues of the Journal of Dental Education have pointed to the importance of faculty buy-in for successful curriculum development.16,18–20 It is in this context that we sought to understand faculty perceptions regarding continuation of two key elements of the Pipeline program: curriculum change regarding community-based extramural rotations and URM/LI recruitment programs. After controlling for individual faculty sociodemographic and contextual characteristics, our analyses indicate that type of faculty and certain faculty perceptions are correlated with their opinions about extramural rotations and URM/LI recruitment programs continuing as integral parts of the school’s educational role.

Extramural faculty members were among the most enthusiastic supporters of both programs. The key objective of sending students on sixty days of extramural rotations necessitated the involvement of dentists and providers outside the main school clinics: dentists and other oral health professionals at community health centers, community dentists, and safety net providers. These individuals became partners with the dental school in training students as they rotated through the community facilities. For many of these providers, it was likely the first time they had been brought into the educational fold at the dental school, a role they seem to have adopted with much enthusiasm. Some were graduates of the same dental schools and realized the additional value these extramural rotations provided the students, both in terms of exposure to "real life" patients and dental practice.

On the other hand, core faculty members at the dental school might not have been fully briefed about the nature of the rotations and thus might have had concerns about adequate training and supervision at the extramural sites. Another concern might have been the potential loss of core faculty positions if more clinical education was shifted to community-based sites staffed by practitioners with adjunct, part-time appointments. These factors could contribute to the core faculty’s relative lack of enthusiasm for the rotations.

The perception of "success" was also key in responses about continuation. For extramural rotations, success could be conceptualized in terms of a faculty member’s perception of student productivity and whether the rotations were a positive factor in students’ education. Greater student productivity could be evident to faculty members when students return to the main school clinics and, coupled with positive student feedback, could contribute to generating a positive perception among the faculty about the extramural rotations, thus strengthening their desire to see the program continue. A school culture that emphasizes community service and promoting access provides the necessary substrate for such perceptions to take hold and persist.

The success of the URM/LI recruitment program, when measured as faculty members’ perception of the effectiveness of the recruitment program, was not a significant determinant. This was not a surprising finding since increasing URM/LI enrollment has proven to be a complex challenge. Not only are schools competing for a limited pool of applicants, but they are also struggling with overcoming institutional culture and inertia that comes into play when this issue is raised. In addition, issues such as Proposition 209 (in California), past history of activity in the area, and people’s individual thoughts regarding affirmative action could be undercurrents that cloud the seemingly simple question. As opposed to this objective measure of success, a more subjective perception—that having students from diverse backgrounds improves the educational experience—was associated with the desire to continue the URM/LI recruitment program. Again, having a mission statement that the school is committed to URM/LI recruitment provided the context in which these values were embraced by individual faculty members.

From a policy and implementation perspective, our analysis suggests three options. First, the extramural faculty members are key stakeholders in the process, insofar as extramural rotations and URM/LI recruitment programs are concerned. Dental school faculty based in the community are often the most enthusiastic about extramural rotations and URM/LI recruitment programs, and schools must ensure that their enthusiasm and support are maintained and conveyed to the core faculty at the school. This could be done by having two-way channels of communication with extramural faculty and by taking steps to ensure that they remain closely connected with the school.

Second, schools must ensure that their successes are widely publicized. For example, an extramural rotation program that serves to increase student productivity should be highlighted in all internal communications of the school. Positive student (and faculty) perceptions about the program should be shared widely, for only by doing so will the school be able to create a groundswell of positive opinion about the program, thus strengthening the necessity for its continuation. Success will truly beget success in this case.

Third, schools must ensure that an appropriate culture exists at their institutions. This is a long-term process, but attitudes toward a service orientation and serving the community, as well as recognizing the importance of diversity in student and faculty ranks, must be nurtured and cultivated.5 Whether this comes from an institutional commitment such as a mission statement or from an activist faculty or student body, each school must choose a path that it is comfortable with. The Pipeline program has provided an impetus and has enabled many schools to embark on this process, and other schools can learn valuable lessons from the Pipeline schools’ experience. (For complete details on and analysis of the Pipeline program at each school, see the forthcoming report to be published as a supplement to the February 2009 Journal of Dental Education.21)

Despite these findings, our study has certain limitations. Our analysis was cross-sectional, which precludes definitive causative assertions. We analyzed data only from the Pipeline schools, so the generaliz-ability of our findings to non-Pipeline schools must be undertaken with caution. In addition, our findings pertain only to the perceptions of faulty members as the Pipeline program was ending. It remains to be seen how these perceptions (and the Pipeline changes at these schools) evolve with the passage of time. Lastly, we were unable to ascertain if there was any systematic difference in the nonresponse rate among the three categories of faculty respondents.


   Conclusion
Top
 Author information
 Abstract
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Despite these limitations, this study advances our understanding of the faculty perceptions that may affect Pipeline program continuation in dental schools. To the best of our knowledge, this study was among the first to explore the individual and contextual factors that affect the relationship. Our findings indicate that faculty perceptions about the continuation of the extramural rotation and URM/LI recruitment programs at Pipeline schools vary by faculty type and perceptions of the program’s success in achieving its goals. To increase faculty perceptions that these programs continue as integral parts of each school’s educational mission, Pipeline schools should develop mechanisms to ensure that extramural faculty members remain key players in Pipeline programs, widely publicize their successes, and develop a service-oriented culture. Future research is needed to ensure the generalizability of these findings to the non-Pipeline dental schools.


   Acknowledgments
 
We acknowledge the entire UCLA National Evaluation Team, Drs. Pamela Davidson, James Freed, Judith-Ann Friedman, Edmond Hewlett, and James Crall and Ms. Daisy Carreon, 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.


   Author Information
Top
 Author information
Abstract
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Dr. Thind is Canada Research Chair in Health Services Research and Associate Professor, Department of Epidemiology and Biostatistics, Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario; Dr. Atchison is Professor, School of Dentistry, University of California, Los Angeles; Dr. Andersen is Professor, Department of Health Services, School of Public Health, University of California, Los Angeles; Mr. Nakazono is Programmer Analyst, Department of Health Services, School of Public Health, University of California, Los Angeles; and Mr. Gutierrez is Project Manager, Dental Pipeline Evaluation, Department of Health Services, School of Public Health, University of California, Los Angeles. Direct correspondence and requests for reprints to Dr. Amardeep Thind, Center for Studies in Family Medicine, University of Western Ontario, 245-100 Collip Circle, London, Ontario N6G 4X8, Canada; 519-858-5028 phone; 519-858-5029 fax; athind2{at}uwo.ca.


   REFERENCES
Top
 Author information
 Abstract
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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