| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Chapter 2 |
Key words: dental education environment, community-based clinical education, minority student recruitment, dental program administration
This chapter begins with background information on the environment that led to the initiation of the Pipeline, Profession, and Practice: Community-Based Dental Education program and reviews antecedent Pipeline programs, the program’s funders, and the rationale for the program’s objectives. Then, it describes the operation of the Pipeline program, emphasizing the role of the National Program Office (NPO) in supporting the funded schools and communicating with the key stakeholder groups.
 |
Background |
|---|
 TopAuthor information Background Dental pipeline programConclusionsReferences |
|---|
Finances.
Starting in the late 1980s, many dental schools experienced a significant decline in public (state and federal) financial support.2 During the same time period, the average income of private practitioners increased at twice the rate of that of clinical faculty, making it difficult for schools to recruit and retain clinical faculty members.3 These financial challenges, which led to competing demands for increasingly limited school resources, made it difficult for participating schools to make the programmatic changes required by the Pipeline program.
Student Diversity.
During the Pipeline period, applications to dental school grew rapidly, as did the grade point average of enrolled students.4,5 Along with the very high cost of a dental education and the decline in public funding for underrepresented minority (URM) student scholarships, it was an especially difficult time for Pipeline schools to recruit more URM students.
Clinical Education.
Dental school clinics are organized as teaching laboratories, where students provide care to patients under the close supervision of faculty. Staffed primarily with students and residents, dental school clinics are not organized to provide care efficiently to large numbers of patients, and students treat only two or three patients per day. As a result, dental school clinics require large operating subsidies.6
Nevertheless, senior students and residents collectively do generate substantial patient revenues. With schools under financial pressure, the loss of these funds when students and residents are assigned to community clinics is a potentially significant problem. While it is true that clinic expenses exceed revenues, schools cannot capture the savings from reduced expenses in the short run because of high fixed costs. Thus, it is reasonable to expect some internal resistance to sending senior students and residents to community clinics and practices.
Community Clinics.
Community clinics are organized as patient-centered delivery systems (i.e., their primary goal is patient care). Senior students and residents assigned to these clinics have access to trained dental assistants and administrative staff that are not available in dental school clinics. Senior students often see six to eight patients per day in community clinics. Also, in contrast to dental school clinics, community dentists continue to treat their own group of patients, as they supervise one or two students or residents.7
A key issue is the impact of students and residents on clinic revenues. Since community clinics are not in a position to subsidize dental education, the long-term feasibility of community-based dental education depends on students and residents having a positive impact on community clinic finances.8
Relevant Antecedent Projects
Two previous projects of the Pipeline program’s co-directors, Dr. Howard Bailit and Dr. Allan Formicola, were critical to the development of the Pipeline program. In 1995, Dr. Bailit received a grant from the Josiah Macy, Jr. Foundation to determine the educational and economic feasibility of moving a large component of clinical education for senior dental students and general and pediatric dentistry residents from dental schools to community clinics and practices that care for underserved populations. After three years of studying these issues, the project concluded that "well-run community programs have the potential to enhance the education of students and residents, to reduce the financial challenges now facing dental schools and students, and to make care more accessible to the underserved." This Macy study helped lay the foundation for dental school and practitioner support for the expansion of community-based dental education programs.7
During his tenure as dean of the Columbia University School of Dental Medicine, Dr. Formicola initiated a comprehensive service-learning program, Community DentCare, to address the oral health needs of low-income residents living in the neighborhoods surrounding the dental school in northern Manhattan. Initially funded by the W.K. Kellogg Foundation, this project later became part of Kellogg’s grant program Health Care for the Underserved. Working with local community organizations, this project had a significant impact on reducing access disparities for many medical and dental services and established an educational and service model for other academic health centers and dental schools to follow in addressing the health needs of underserved populations.9
Foundation Support for the Pipeline Program
The Robert Wood Johnson Foundation (RWJF) is the largest foundation in the United States devoted exclusively to the improvement of health and health care. In the late 1990s, RWJF noticed a significant upturn in unsolicited proposals related to dental access disparities. When this development was coupled with the release of the U.S. surgeon general’s report on oral health, the foundation decided to focus on the access problem. A senior program officer, Ms. Judy Stavisky, who had at the time been recently hired, spent eighteen months meeting with key people and organizations interested in oral health. She became aware of the successful DentCare program at Columbia University and the promising findings from the Macy study. From these experiences, Ms. Stavisky designed a strategy to address access disparities built around dental education. The Pipeline program was approved by the RWJF Board of Trustees in May 2001. Soon after, the W.K. Kellogg Foundation joined the Pipeline effort by giving the American Dental Education Association (ADEA) $1.1 million to provide financial assistance to underrepresented minority dental students recruited by Pipeline schools.
In February 2003, The California Endowment (TCE), the largest private health foundation in California, decided to participate in the Pipeline program and provided support to four of California’s five dental schools to participate (the program at the University of California, San Francisco had already been funded by RWJF).
Rationale for Pipeline Objectives
The primary goals and objectives of the Pipeline program were presented in Chapter 1.1 This part of Chapter 2 provides the rationale for those objectives.
Community-Based Education.
The community-based dental experiences were expected to have an immediate impact on increasing care to underserved patients. As previously noted, senior students and residents are able to see substantially more patients and provide more services in patient-centered community delivery sites than in dental school clinics.7 Thus, increasing the time that senior dental students spend in community clinics from ten days at baseline to sixty days should result in thousands more underserved patients receiving care. A related issue is the potential impact of community experiences on student careers. Although the literature we consulted was inconclusive, the hope was that some graduates would work in safety net clinics; others would locate their practices in underserved areas; and more would treat underserved patients, regardless of their practice location. The impact of community experiences on the quality of dental education was another primary concern. Fortunately, several schools (such as the University of Colorado, Harvard University, and Boston University) had extensive experience with this model of dental education and reported positive results.10–12 A final consideration was the potential impact of community-based education on school finances. Many schools were experiencing serious financial problems and could not sustain community-based education programs if they resulted in a net loss of revenues. The literature on community-based education provided little information on this important issue.
Curriculum Change.
Curriculum changes were necessary to prepare students for their community experiences. Of special importance, students must be culturally competent to treat a diverse group of patients and have a basic understanding of clinical epidemiology, public health, and patient behavior. They must also be clinically competent in the basics of general dentistry before working in community clinics.
Underrepresented Minority Students.
There is substantial evidence that URM dental and medical graduates are much more likely to care for underserved patients than other graduates.13,14 Of equal importance, there is convincing evidence that minority and low-income patient compliance and satisfaction with care—two important quality of care measures—are improved when they are treated by practitioners of the same cultural and linguistic background.15 Also, as the 2003 U.S. Supreme Court decisions regarding affirmative action pointed out, a diverse student body benefits all students.16
|
Dental Pipeline Program |
|---|
|
TopAuthor informationBackgroundDental pipeline programConclusionsReferences |
|---|
The committee was chaired by Dr. Caswell Evans, a prominent public health dentist who directed the preparation of the U.S. surgeon general’s report on oral health. The members of the committee and their affiliations are presented in Table 2.1
.
|
lists the eleven schools selected by the NAC to receive RWJF awards and the four schools that received subsequent TCE grants. The selection criteria included the quality of the applications and distributional equity with respect to regional, public/private, and minority/nonminority variation among schools.
|
National Program Office, Budget, and Schedule
The National Program Office (NPO) was based at Columbia University in the Center for Community Health Care, and project staff members were located at Columbia (Formicola) and the University of Connecticut Health Center (Bailit). Kim D’Abreu, the project’s deputy director, was recruited from the State University of New York Downstate Medical Center, where she had worked for ten years recruiting URM medical students.
The RWJF award was for $19 million over six years. Of this amount, $4 million was for the NPO to administer the project, and the eleven schools received an average $1.2 million each over five years. The TCE grant was for $6.3 million and was allocated the same way. Kellogg and TCE provided a total of $1.6 million for financial aid. Overall, the three foundations provided $26.4 million for the Pipeline initiative.
During the final year of the grant, $200,000 from the original $19 million was allocated to four Pipeline schools to support mentoring programs. The funded dental schools were at the University of Connecticut, Meharry Medical College, University of Southern California, and University of Illinois at Chicago.
TCE also funded two separate projects related to the Pipeline program. Ms. Shelley Gehshan from the National Conference of State Legislatures received a grant to study California stakeholder perceptions of dental care access barriers and strategies for overcoming these barriers. Dr. Paul Glassman from the Arthur A. Dugoni School of Dentistry at the University of the Pacific surveyed dental safety net clinics in California. The Gehshan and Glassman reports are available on the Pipeline website.17,18
In addition, many Pipeline schools applied to external local and national funders to supplement or expand their Pipeline activities. The total funds generated from external sources came to over $13 million. The grants came mainly from local foundations and insurance companies that are concerned with access disparities and student diversity.
The first year (2001–02) of the six-year project was spent establishing the NPO office at Columbia University and selecting schools to participate in the program. Once selected, the eleven RWJF-funded schools were given twelve months (2002–03) to plan for the implementation of the project, which began July 2003. For the TCE-funded schools, the planning period was shortened to six months (July 2003 to December 2003), and implementation began in January 2004. The project ended in the summer of 2007.
Activities Directed by the NPO
The NPO undertook three primary types of activities in administering the Pipeline program.
Community-Based Dental Education.
To meet the goals of the program, students were required to spend sixty days practicing in a patient-centered community clinic. Some schools owned community clinics but ran them as teaching laboratories rather than as real delivery systems. The NPO did not count student time in these clinics for the sixty-day objective because they were not patient-centered. To meet Pipeline objectives, these schools had to contract with patient-centered community clinics run by other organizations. This was a challenge, but the schools were successful in making the arrangements for extramural rotations. One school was able to transform its community clinic into a patient-centered delivery system.
One-week student assignments to a specific clinic were generally unsuccessful because it takes time for the community faculty to get to know students and for students to understand how clinics operate. Short assignments also limit the complexity of the services (e.g., bridges, partial dentures) that can be provided by students. In contrast, schools that assigned students to one community clinic for at least three weeks and preferably longer had more productive experiences. The NPO encouraged all schools to have rotations of three or more weeks per community site.
Most dental schools require students to complete a specified number of clinical procedures in order to graduate. Initially, faculty members at several schools were reluctant to give students credit for services provided during their off-site rotations. Had they not received credit, students with already crowded schedules and trying to complete many graduation requirements would likely have viewed their community assignments negatively. The NPO was successful in convincing these schools to give students credit for the services they completed in community clinics.
To expand students’ knowledge and attitudes about the underserved, the NPO also encouraged schools to hold post-rotation seminars in which students could reflect upon and discuss their community experiences with other students and faculty members. The goal was to broaden the participants’ views and help them become better professionals and individuals.
Cultural Competence.
Cultural competence training was readily adopted by schools because schools and community clinics treat a wide diversity of patients. The NPO worked with the schools to extend cultural competence training to the faculty and staff: the former because students model their behavior on that of the faculty, and the latter because patients interact with staff.
Recruitment.
Few schools had very much experience recruiting URM students. Working with national experts, the NPO held several workshops for Pipeline schools on URM recruitment programs and admission policies. TCE required that the five California schools cooperate on recruitment activities. This requirement prompted the NPO to form the California Recruitment Collaborative; based on this model, six schools in the Northeast formed a comparable Northeast Regional Recruitment Collaborative. The major activities of these collaboratives were
Technical Support
The NPO’s technical support involving helping schools deal with specific operational issues related to the implementation of the Pipeline program. The NPO used many strategies to provide this support.
Several involved more formal means. First, the NPO identified special topics of concern to multiple schools and invited experts to make presentations at annual national Pipeline meetings. For example, the dean of admissions at Duke University School of Medicine gave a presentation on Duke’s strategy to change its admissions process to enroll a more diverse student body. Second, several workshops were held outside the framework of the annual meeting, at which external experts made presentations and schools reported on their strategies and programs. All schools attended these special meetings. Third, small groups of external experts were sent to individual schools to address topics of interest such as the use of "whole file" review by admissions committees. These were organized by the NPO at the request of schools, and the NPO partly subsidized these visits. Fourth, at the request of individual schools, the NPO identified expert consultants and asked them to visit the school to address specific problems. Many, but not all, of these consultant visits were subsidized by the NPO.
In many informal contacts with faculty, the co-directors and deputy director discussed problems and offered suggestions to solve them. The advice was based on the expertise of the directors, their knowledge of activities at other schools, and their general management experience. Most problems related to dealing with faculty, staff, and stakeholder groups (e.g., how to convince faculty members to give credit for work performed during community rotations). This assistance was often offered by the NPO without the school recognizing the need for it, suggesting that proactive leadership is a necessary component of effective technical assistance.
Monitoring School Performance
Four basic sources of information were used to monitor school performance: semiannual conference calls, site visits, the annual implementation report, and informal contacts with faculty members.
Schools were called biannually to review their progress. A formal agenda was prepared for the conference call, and minutes were taken. The calls were scheduled for one hour, and the participants usually included the NPO co-directors and deputy director, RWJF and TCE program officers, and key school faculty members and staff.
The schools were site-visited every other year. The participants in these visits included at least one NPO co-director, the deputy director, and a member of the NAC. School participants included the dean, project director, selected faculty members and staff, and several students; in California, residents were also included. The RWJF and/or TCE program officers also participated. The NPO and the school prepared the meeting agenda for the site visit, and a briefing book was prepared for the site visitors. The site visits started with the dean welcoming the visitors and giving a general overview of the school and the importance of the Pipeline program. Then, the project director and faculty members reviewed each major program component. A high point of the visits was an executive session with students and residents. These participants provided unfiltered information on how the school was running the program and usually offered constructive suggestions on how to improve program operations.
In addition, working with the NET, the NPO developed a reporting form that all schools completed each August. The report provided a detailed review of the preceding academic year’s achievements and challenges and presented the objectives for the next academic year. The major categories of information collected in the implementation report were 1) a narrative on the progress made in achieving Pipeline objectives; 2) a description of each community site; 3) the average number of days that students/residents spent in community sites; 4) course changes in public health, behavioral sciences, and cultural competence; 5) the number of URM applicants, including the number interviewed, enrolled, and graduated; 6) a description of long- and short-term pipeline URM recruitment programs; and 7) the objectives and activities for the upcoming year.
Finally, the co-directors and deputy director had frequent informal contacts with faculty and staff from the participating schools as part of the Pipeline program’s internal committee structure. In addition, the co-directors met with faculty members at national dental education and research meetings. These activities offered many opportunities to discuss Pipeline program activities with each school’s faculty.
Communication with NET and Stakeholders
Dr. Bailit had primary responsibility for interfacing with the NET. This included monthly conference calls to address common concerns and a face-to-face meeting at least once each year. Further, a detailed and specific plan for publications was established to keep each group aware of the others’ activities and to resolve any conflicts about publications. Finally, the NET attended and participated in all annual Pipeline meetings and special activities.
A communications plan was developed for major stakeholder groups: organized dentistry; organizations representing Hispanic, African American, and American Indian dentists; dental educators; federal agencies; and the public health community.
Means of communication began with the www.dentalpipeline.org website, which was developed for the NPO to communicate with Pipeline and other dental schools and stakeholder groups. The site described the purpose of the Pipeline program, listed the participating schools, provided the rationale for the project objectives, and, in a resource section, suggested key articles for each program objective. There was a separate section on the site for the California program. Also, a monthly e-newsletter was published. The website received several hundred visitors each month.
NPO communication efforts focused on the major dental organizations in the United States: the American Dental Association (ADA), Hispanic Dental Association (HDA), National Dental Association (NDA), and Society of American Indian Dentists (SAID). Because 75 percent of dentists belong to the ADA, no special efforts were made to communicate with specialty dental organizations and the Academy of General Dentistry.
A past ADA president, Dr. Robert Anderton, was on the NAC. The first national meeting of the Pipeline schools took place at ADA headquarters in Chicago and was partially subsidized by the ADA. This meeting gave a strong national message that the ADA was solidly behind the Pipeline program. In addition, Dr. Bailit was invited each year to present progress on the Pipeline program to the ADA Board of Trustees and senior staff. The ADA also often asked Dr. Bailit to present updates on the Pipeline program at special ADA meetings on access disparities and dentist diversity.
As ties between the Pipeline program and the ADA strengthened, the ADA decided to provide funds for some Pipeline activities. These included scholarships for underrepresented minority and low-income students and transportation for students to attend the Summer Medical and Dental Enrichment Program (SMDEP), a new (to dentistry) RWJF-sponsored program for disadvantaged college students interested in dentistry and medicine.
A component society of the ADA, the California Dental Association (CDA), also played a prominent role in the Pipeline program. Dr. Bailit gave annual presentations to the CDA Board of Trustees, and several CDA leaders participated in the annual California Pipeline meetings. The CDA was a strong advocate of the Pipeline program, and the CDA Foundation provided substantial funds to support the postbaccalaureate programs in Southern and Northern California.
The underrepresented minority dental organizations were also actively involved. A member of the NAC, Dr. Ernest Garcia, was a prominent HDA leader and past president. A member of the NPO attended all annual HDA national meetings, and Dr. Bailit gave formal presentations on the Pipeline program at three of the association’s meetings. Another member of the NAC, Dr. Edward Scott, was a past NDA president. The co-directors met with the NDA Board of Trustees several times, and at least one NPO director or the deputy director attended the annual NDA national meetings. At several NDA meetings, the NPO staff gave formal presentations on the Pipeline program. Another member of the NAC, Mr. Jerry Tahsequah, was active nationally in efforts to recruit more American Indians into the health professions. Dr. Bailit maintained communications with the SAID and attended one of this organization’s annual national meetings.
As for dental education, ADEA was a major champion of the Pipeline program. Dr. Formicola provided annual Pipeline reports to the ADEA Board of Directors and Council of Deans, and Pipeline symposia were organized at national ADEA meetings. Some important ADEA Pipeline activities included the following:
As for federal agencies, a member of the NAC, Dr. Isabel Garcia, was a senior officer in the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH). Dr. Bailit took the lead in communicating with federal agencies, including the NIDCR, Health Resources and Services Administration (HRSA), and Centers for Disease Control and Prevention (CDC). Annually, the NIDCR organized a meeting of all federal agencies related to oral health, and Dr. Bailit presented an overview of the Pipeline program to these agencies.
In addition, several leaders of the dental public health community were members of the NAC, including Dr. Evans and Dr. Garcia. Dr. Bailit and Dr. Formicola also organized Pipeline symposia at the national meetings of the American Public Health Association, American Association of Public Health Dentistry, and ADEA.
|
Conclusions |
|---|
|
TopAuthor informationBackgroundDental pipeline programConclusionsReferences |
|---|
|
Author Information |
|---|
|
TopAuthor informationBackgroundDental pipeline programConclusionsReferences |
|---|
|
REFERENCES |
|---|
|
TopAuthor informationBackgroundDental pipeline programConclusionsReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  R. M. Andersen and P. L. Davidson Introduction to the Evaluating the Dental Pipeline Program Report J Dent Educ., February 1, 2009; 73(2_suppl): S10 - 14. [Full Text] [PDF]
|
|
|
|
|
|
P. L. Davidson, T. T. Nakazono, A. Afifi, and J. J. Gutierrez Methods for Evaluating Change in Community-Based Dental Education J Dent Educ., February 1, 2009; 73(2_suppl): S37 - 51. [Full Text] [PDF]
|
|
|
|
|
|
R. A. Kuthy, M. Woolfolk, H. L. Bailit, A. J. Formicola, and K. C. D'Abreu Assessment of the Dental Pipeline Program from the External Reviewers and National Program Office J Dent Educ., February 1, 2009; 73(2_suppl): S331 - 339. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
