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J Dent Educ. 72(4): 422-430 2008
© 2008 American Dental Education Association
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Milieu in Dental School and Practice

Dentists’ Comfort in Treating Underserved Populations After Participating in Community-Based Clinical Experiences as a Student

Michelle R. McQuistan, D.D.S., M.S.; Raymond A. Kuthy, D.D.S., M.P.H.; Keith E. Heller, D.D.S., Dr.P.H.; Fang Qian, Ph.D.; Katharine J. Riniker, D.D.S.

Key words: attitude of health personnel, dentist comfort, extramural, frail elderly, dental care for disabled, homebound

Submitted for publication 08/01/07; accepted 12/10/07


   Abstract
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Methods
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 Discussion
 References
 
The purpose of this project was to determine new dentists’ comfort levels in treating traditionally underserved populations after participating in two consecutive five-week community-based clinical experiences while in dental school. A written survey was mailed to all known University of Iowa alumni (1992–2002; N=745). Respondents were asked to rank their comfort levels in treating twelve underserved populations on a five-point Likert type scale (5=no problem; 1=will not). Bivariate and logistic regression model analyses were performed to examine associations (p<0.05) among comfort and six predictor variables. Alumni (n=372) were most comfortable treating other ethnic, low-income, non-English-speaking, and HIV+/AIDS populations and least comfortable treating incarcerated and homebound populations. The following variables were significantly associated with comfort: 1) perception that the community experiences had great/much value; 2) practice located in larger communities; 3) non-solo practitioners; and 4) dentist’s gender. As more dental schools utilize community-based clinical experiences to increase students’ exposure to underserved populations, it is important that these experiences provide exposure to a variety of populations. Additionally, dental schools should continuously monitor the short- and long-term value of these programs for their students and recent graduates.

In 2004, 64 percent of U.S. adults between the ages of eighteen and sixty-four had at least one dental visit;1 however, this means that approximately 75 million adults in this age range did not receive dental care that year. Although some people may not perceive that they need care, others may not be able to overcome the barriers they face in obtaining dental care. While barriers such as transportation, finances, language, and dentists’ availability can contribute to the access challenges traditionally underserved patients must overcome,2,3 these are not the only barriers faced by these populations. Indeed, health care providers’ attitudes and perceived comfort in treating specific populations have been noted as contributing to the access problem.4 For example, a survey of Vancouver dentists found that only 19 percent of respondents treat elderly patients living in long-term care facilities.5 In general, most of the responding dentists did not feel adequately trained to treat patients in long-term care facilities, nor were they interested in providing care within this setting.5 Similarly, over 50 percent of Michigan dentists reported that they were not at all well prepared or not well prepared to treat patients with special needs or mental retardation.6

Health care students who are exposed to under-served populations in clinical settings are more likely to have positive attitudes towards those populations.7–10 Among medical students, those who held more positive attitudes towards people with disabilities were more likely to feel comfortable treating disabled patients.11 Furthermore, other studies have found that increasing students’ confidence and perceived competence in treating underserved populations (e.g., elderly12 and disabled13 patients) also influenced students’ attitudes toward treating underserved populations. As a result, community-based clinical experiences have been developed to expose students to populations typically not seen at dental schools. It is hoped that this exposure will help new dentists feel more comfortable treating these populations once they graduate from dental school.

While several studies exist pertaining to dental and medical students’ attitudes regarding the elderly, disabled, and HIV+/AIDS patient populations,7,9,11,14–18 limited data exist pertaining to dentists’ comfort levels in treating these populations.19 Furthermore, there is even less data regarding dentists’ comfort levels in treating other underserved populations, such as the homeless and incarcerated. Our study is valuable because it describes new dentists’ comfort in treating a variety of underserved populations, many of whom have never been reported in the literature.

The purpose of this project was to determine new dentists’ comfort levels in treating traditionally underserved populations after participating in two consecutive five-week community-based clinical experiences while in dental school.


   Methods
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A twenty-five-item written survey was developed to assess new University of Iowa College of Dentistry graduates’ (1992–2002; N=769; known addresses n=745) comfort levels in treating twelve traditionally underserved populations. The survey also included questions regarding the perceived value the dentists placed on the community-based clinical experiences in preparing them to treat underserved populations and the percentage of underserved populations actually treated, which will be described in another report. The selected populations were low- income, frail elderly, mentally compromised, medically complex, homebound, homeless, jail inmates, known drug users, HIV+/AIDS patients, Medicaid, non-English-speaking patients, and other ethnic groups. These populations were chosen based on the populations the new dentists typically treated as students during their community-based clinical experiences. Prior to distribution, Institutional Review Board approval was obtained, and the survey was pilot-tested for content validity and clarity.

After obtaining a mailing list from the University of Iowa alumni office, the survey was sent with a self-addressed, stamped return envelope to dentists who had been in practice for one to eleven years at the time of the mailing of the survey. The first survey was mailed in July 2003, and a second survey was mailed to nonresponders in August 2003. A follow-up postcard was mailed in September 2003. Since it has been mandatory for all University of Iowa dental students to participate in community-based clinical experiences since the 1970s, all dentists who graduated between 1992 and 2002 were invited to participate in this study.

The survey asked dentists to rate how comfortable they are treating each underserved population based on a five-point Likert type scale with 5=No Problem, 4=OK, 3=Some Concern, 2=Rather Not, and 1=Will Not. Because the goal of the study was to determine who is comfortable treating underserved populations, the dependent variable, comfort, was dichotomized into "No Problem/OK" vs. "Some Concern/Rather Not/Will Not." This dichotomization helped to distinguish the responding dentists who are comfortable treating a specific population (Comfort=Yes; "No Problem/OK") from those who are not (Comfort=No; "Some Concern/Rather Not/Will Not). Dentists were also asked questions relating to the following predictor variables (reference groups are indicated with an asterisk): dentist’s gender (male vs. female*); years since graduation (1998–2002 vs. 1992–97*); community–based clinical experience program combination in which the dentists participated (BMC-SC or BMC-Oth vs. SC-Oth*; see next paragraph for categories); dentists’ perceived value of their community-based clinical experiences (Great/Much Value vs. Some/Little/No Value*); their current practice status (non-solo vs. solo*); and the size of the community in which their practice is located (>250,000 or 25,000–250,000 vs. 0–24,999* people).

Because all of the dentists participated in two consecutive five-week community-based clinical experiences (ten weeks total) as dental students, the dentists’ experiences were classified as program combinations to represent their total experience. From 1992 to 2002 these experiences took place in the following practice settings: 1) Broadlawns Medical Center; 2) Special Care Program; and 3) Other sites. Broadlawns Medical Center (BMC) is a safety-net county hospital with an associated medical and dental outpatient facility located in Des Moines, IA. Historically, the BMC has been identified as the number one hospital in the country treating the largest percentage of uninsured patients (greater than 50 percent uninsured). As such, when the dentists were students, they were exposed to a large number of low-income patients who received treatment based on a sliding fee scale. Additional characteristics of some of the Broadlawns patients treated in the dental clinic include non-English-speaking patients, "other ethnic groups," medically compromised and HIV+/AIDS patients, incarcerated patients, drug users, and homeless patients. The Special Care Program is a university-based program consisting of a Special Needs Clinic located within the College of Dentistry (Iowa City, IA) and a nursing home mobile unit that provides treatment at ten regional nursing homes utilizing portable equipment. The populations treated within this program include the frail elderly, medically compromised, mentally challenged, homebound, incarcerated, homeless, low-income, and Medicaid patients. "Other site" examples include rural private practice preceptorships, community health clinics, and Veterans Affairs hospitals (IA); Colorado Migrant Program (CO); and Indian Health Service (MI, MT, NM, AZ). The populations treated in each clinic varied by location. The program combination categories utilized for this study were chosen based on the most commonly attended program combinations, specifically the following: Broadlawns-Special Care (BMC-SC); Special Care-Other (SC-Oth); and Broadlawns-Other (BMC-Oth). The group "Other-Other" was eliminated from statistical analyses because so few respondents (n=22) participated in two "Other" experiences.

Survey data were double-entered into a database and statistically analyzed using SAS 9.0 (statistical software, SAS Institute, Inc., Cary, NC). Separate statistical analyses (descriptive, bivariate, and generalized logistic regression) were performed for each underserved population. Dentists’ mean and median comfort scores in treating each population were determined. Additionally, mean scores were calculated to describe dentists’ perceptions of the value the community-based clinical experiences had in preparing them to treat underserved populations. Bivariate analyses examining associations between comfort and each predictor variable (e.g., gender) were performed utilizing chi-square, Fisher’s exact, or Cochran-Mantel-Haenszel tests. Predictor variables that were statistically associated (p≤0.05) with comfort in the bivariate analyses for a specific population were included in a generalized logistic regression model that utilized forward stepwise inclusion procedures to identify the predictor variables that were associated (p≤0.05) with dentists’ comfort in treating each underserved population. All possible two-way interactions among statistically significant predictor variables were examined for each model. Additionally, nonresponse biases for gender, years since graduation, and program combinations were analyzed utilizing chi-square and Cochran-Mantel-Haenszel tests.


   Results
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Three hundred seventy-two dentists responded with usable surveys for an adjusted response rate of 50 percent. A description of the responders’ and nonresponders’ characteristics is presented in Table 1Go. Nonresponders were more likely to be male and to have graduated prior to 1998. Additionally, non-responders were more likely to have participated in the Broadlawns-Special Care Program combination compared to responding dentists.


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  		Table 1. Demographic and practice comparisons between responders (n=372) and nonresponders (n=373)
 
Among responders, dentists were most comfortable treating the following populations: other ethnic groups, low-income, non-English-speaking, and HIV+/AIDS patients (Table 2Go). In contrast, they were least comfortable treating homeless, drug users, incarcerated, and homebound patients. Responders perceived that the community-based clinical experiences were most valuable in preparing them to treat low-income populations, medically complex patients, and the frail elderly. The programs were perceived as less valuable in preparing the dentists to treat incarcerated and HIV+/AIDS patients.


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  		Table 2. Dentists’ comfort in treating underserved populations and the value of community clinical experiences in preparing dentists to treat these populations (n=372)
 
Bivariate analyses demonstrated that dentists’ gender, practice type, community size, and perceived value of the community-based clinical experiences were significantly (p≤0.05) associated with dentists’ comfort in treating the selected populations (Table 3Go). However, none of the predictor variables were significantly associated with all twelve populations. For example, dentists’ gender was significantly associated with their comfort in treating incarcerated patients, but it was not significantly associated with their comfort in treating any other population. Similarly, dentists’ perceptions of the value of their community-based clinical experiences were significantly associated with their comfort in treating low-income, mentally compromised, frail elderly, and incarcerated populations, but value was not associated with dentists’ comfort in treating the remaining populations. Neither years since graduation nor program combinations were significantly associated with dentists’ comfort in treating any of the populations; thus, these two variables were not included in further analyses.


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  		Table 3. Significant findings (p≤0.05) from the bivariate analyses between comfort (yes/no) in treating each under-served population and select predictor variables (n=372)*
 
Separate generalized logistic regression models were run for each population. The results show that the significant (p≤0.05) predictor variables associated with each comfort model varied by population (Table 4Go). For example, holding all other variables constant, dentists who practice in non-solo environments were 2.4 times as likely to feel comfortable treating low-income populations compared to solo practitioners. Additionally, dentists who perceived that their community-based clinical experiences had great or much value were 2.3 times as likely to feel comfortable treating low-income populations compared to dentists who perceived that their experiences had some, little, or no value. In contrast, neither of these two predictor variables was significantly associated with dentists’ comfort in treating non-English-speaking patients. No statistical interactions were found.


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  		Table 4. Logistic regression models for comfort (yes/no) in treating each underserved population (n=372)
 

   Discussion
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As more dental schools implement or expand community-based clinical experiences within their curricula, it is important to assess the long-term impact of these programs relating to dentists’ comfort, competence, and willingness to treat traditionally underserved patients. Because many of the community-based clinical experience programs across the country are relatively new, limited data exist pertaining to the outcomes of these programs. This study is important because it provides a base level of knowledge relating to new dentists’ comfort in treating underserved populations, many of whom have never been studied. Because many of the dependent and predictor variables utilized in this study have not been previously cited in the literature, it was difficult to compare this study to other studies. However, when comparisons are available, they are discussed.

As a whole, new University of Iowa dental graduates are generally comfortable treating a variety of underserved populations. However, the dentists’ comfort levels varied by population. Additionally, the statistically significant predictor variables associated with dentists’ comfort varied among populations. This suggests that dentists’ comfort in treating traditionally underserved populations is a complex process that involves the dentists’ educational and professional experiences, personal preferences and characteristics, and a multitude of external influences. Indeed, a study examining dentists’ willingness to provide care for patients with developmental disabilities found that other factors, such as third party reimbursement, increased treatment time, and special equipment and facilities, as well as dentists’ attitudes, need to be considered in determining who is willing to treat underserved populations.20

Four main predictor variables were statistically significantly associated with dentists’ comfort in treating underserved populations. These predictor variables were practice type, community size, perceived value of the community-based clinical experience, and the dentist’s gender. This study found that non-solo dentists were more likely to be comfortable treating low-income, Medicaid, mentally compromised, and drug user patients compared to solo dentists. It has been suggested that dentists in non-solo practices have a greater potential for sharing treatment ideas and philosophies, and they also have the ability to make internal referrals.21 By providing students with a baseline level of comfort in treating underserved populations during their community-based clinical experiences, new dentists in non-solo practices may feel more comfortable treating under-served populations knowing that they can consult with their colleagues regarding patient management or treatment when necessary.

Similarly, this study also found that dentists from larger communities (>250,000 people) were more likely to feel comfortable treating non-English- speaking, HIV+/AIDS, mentally compromised, medically complex, and homebound patients compared to dentists who live in smaller communities (0–24,999 people). Like non-solo dentists, dentists in larger communities may be more comfortable treating underserved populations because they have greater access to other dentists, health care providers, and specialists with whom they can discuss their patients or to whom they can refer. In contrast, dentists in smaller communities may not have similar resources. Thus, dentists in smaller communities may feel less comfortable treating specific populations. This is problematic because Allison and Manski found that residents in rural areas had lower levels of dental utilization than residents in micropolitan or metropolitan areas.22 If dentists in smaller communities feel uncomfortable treating specific underserved populations, such as the homebound, dental utilization by these populations in rural communities may be even lower due to the limited supply of dentists willing to treat them. Among all responding dentists, only 32.2 percent of the respondents felt comfortable treating homebound patients. Dental schools should try to include opportunities for dental students to treat homebound patients during their community-based clinical experiences to increase their comfort in treating this population.

Over 50 percent of the respondents perceived that the community-based clinical program provided much or great value in preparing them to treat seven of the twelve identified underserved populations (Table 2Go). This suggests that dentists value the unique experiences provided by the program. Dentists perceived that the program was the most valuable in preparing them to treat low-income, mentally compromised, and frail elderly patients. Similarly, perceived value was statistically significantly related to dentists’ comfort in treating these same populations (Tables 3Go and 4Go). This suggests that dentists place more value on experiences that contributed to their comfort in treating specific populations compared to experiences that did not contribute to their comfort.

One of the purposes of a community-based clinical experience is to expose dental students to populations not typically treated within the student clinics of a dental school. It is hoped that increased exposure to these populations will increase students’ (and dentists’) comfort in treating these populations. A recent study conducted in the United Kingdom found that dental and hygiene students who participated in a community-based clinical experience reported increased confidence treating "unfamiliar patient types."23 Furthermore, Smith et al. found that student and alumni attitudes towards treating underserved patients were significantly correlated with their dental education.19 When developing and evaluating community-based clinical programs, student and alumni feedback should be obtained to assess how they judge the value of the program and what components of the program were valuable in preparing them to treat underserved populations.

Community-based clinical experience program combinations, years since graduation, and dentists’ gender were never or rarely associated with dentists’ comfort in treating any of the selected populations. Because dentists were exposed to a variety of under-served patients within their two program combinations, the total overall experience among the program combinations may be very similar, thus minimizing the association between program combinations and dentists’ comfort. If one were able to examine dentists’ comfort in treating a specific population based on participation within a specific rotation (e.g., frail elderly and the Special Care Program), participation in a specific community-based clinical experience may have been statistically significant with dentists’ comfort. However, since new dentists tend to view their experiences as a whole, it would be difficult to separate the skills and experiences learned in one rotation versus the other for this study. Future studies should be conducted to determine how participation in one vs. two or more community-based clinical experiences is associated with dentists’ comfort in treating specific populations. Based on the results of these studies, dental schools can develop or modify their community experiences to increase dentists’ comfort in treating targeted populations.

There may be many reasons why years since graduation was not significantly associated with dentists’ comfort. Overall, community-based clinical experiences were fairly consistent between 1992 and 2002; thus, dentists were exposed to similar patient populations. Participating in similar experiences would minimize the association between years since graduation and dentists’ comfort. Alternatively, the lack of an association may be due to varying perceptions of comfort immediately after graduation and after one has been in practice. Recent graduates may correctly or incorrectly view themselves as comfortable and competent to treat all patients immediately after graduation. Over time, this sense of comfort may become stronger and more realistic. Because years since graduation was not associated with dentists’ comfort in treating these populations, future studies should look for alternative explanations to help explain dentists’ comfort in treating underserved populations.

With the exception of treating incarcerated patients, dentists’ gender was not significantly associated with their comfort in treating any of the populations. The difference between male and female dentists’ comfort in treating incarcerated patients may have resulted from feelings related to safety rather than comfort related to having the appropriate technical skills to treat this population. This suggests that variables beyond exposure to a population and clinical skills may impact dentists’ comfort in treating specific populations.

There are some limitations with this study. On the survey, "comfort" was self-defined by the respondents. Nonetheless, the findings of this study imply that differences do exist among dentists regarding their perceptions of comfort in treating various under-served populations. Because this study suggests that dentists consider a variety of factors beyond technical skill when determining their comfort, future studies should also ask dentists if they feel "clinically competent" to treat these populations. By asking dentists about both "comfort" and "clinical competence," it would better support the hypothesis that several variables beyond clinical competence impact dentists’ comfort in treating underserved populations.

Since all University of Iowa alumni were required to participate in the community-based clinical programs as students, it was not possible to study the impact of nonparticipation. Thus, it is difficult to conclude with statistical certainty that the associations found in this study were related to the community-based clinical program as opposed to the entire four-year curriculum. Indeed, the dentists may have had limited exposure to some of the un-derserved populations while students at the College of Dentistry; however, the potential to interact with these populations was greater at the community-based rotations. While a comparison group would be ideal from a statistical perspective, the opportunities to perform such a comparison may be diminishing as more institutions have implemented or reconstituted their community-based clinical experience programs. Nonetheless, the results of this study are useful because they identify populations that new graduates are uncomfortable treating even after participation in a community-based clinical experience. Dental schools located in states that have similar populations can use this information to develop or modify their community-based clinical experiences to ensure that students have exposure to these populations.

Overall, this study had a 50 percent usable response rate, which shows that dentists are interested in this topic. Because there were some differences between respondents and nonrespondents (Table 1Go), care should be taken when applying the results of this study to all 1992–2002 Iowa graduates. However, for some variables, such as program combinations, the results of the study were never or rarely statistically significantly associated with dentists’ comfort in treating underserved populations. Therefore, the difference between respondents and nonrespondents on these variables probably does not pose a serious threat to the results.

As with any survey, the results are also limited by the potential for recall and social desirability bias. While the survey instructed respondents to focus on the extramural program’s value in preparing dentists to become comfortable treating underserved populations, respondents may have had a difficult time separating their extramural experiences from their overall dental curriculum (recall bias). Additionally, respondents may have felt that they needed to provide socially acceptable answers regarding their comfort levels treating underserved populations. However, due to the wide range of responses regarding the value dentists placed on the extramural programs (74.6 percent to 25.3 percent) and their comfort in treating various populations (98.5 percent to 32.2 percent) (see Table 2Go), it appears that these biases were limited among respondents.

In general, new University of Iowa graduates feel comfortable treating many, but not all, under-served populations. Their comfort in treating these populations varies based on dentists’ practice type, community size in which the practice is located, dentists’ perceived value of their participation in the community-based clinical experiences, and gender. Years since graduation and program combinations were not significantly associated (p≤0.05) with dentists’ comfort in treating any of the populations. As more dental schools utilize community-based clinical experiences to increase students’ exposure to underserved populations, it is important that these experiences provide exposure to a variety of populations. Additionally, dental schools should continuously monitor the short- and long-term value of these programs for their students and their recent graduates. While this study does provide some insight regarding which variables are associated with comfort, future studies should be conducted to further explore dentists’ comfort in treating underserved populations and how dentists determine the value of a community-based clinical experience. Additionally, future studies should continue to examine the associations among dental education, dentists’ comfort in treating underserved patients, and their actual treatment of these populations.


   Author Information
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Abstract
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 References
 
Dr. McQuistan is Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; Dr. Kuthy is Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; Dr. Heller was Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry at the time of his death; Dr. Qian is Adjunct Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; and Dr. Riniker practices clinical dentistry in Dubuque, Iowa, and worked with this research team while a dental student. Direct correspondence to Dr. Michelle McQuistan, University of Iowa College of Dentistry, 343 Dental Science Building North, Iowa City, IA 52242-1010; 319-335-7524 phone; 319-335-7187 fax; michelle-mcquistan{at}uiowa.edu.

This project was supported, in part, by NIH/NIDCR T32 DE14678 and Dows Student Research Award, University of Iowa College of Dentistry.


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