Students’ Comfort Level in Treating Vulnerable Populations and Future Willingness to Treat: Results Prior to Extramural Participation

Methods

In 1969, the University of Iowa initiated a voluntary extramural program, focusing on a private practice, preceptor model.¹¹ Soon thereafter, the program became mandatory, and within the next decade it shifted focus from the private sector to a more community-based philosophy. Senior dental students now participate in two consecutive, five-week extramural rotations under the administration of the Department of Preventive and Community Dentistry. Students are matched with several in- and out-of-state affiliated programs. Approximately one-fourth of each class rotates to these extramural sites at any one time during the academic year.

A total of 690 senior dental students who graduated from 1992 through 2004 were included in this analysis. Senior students participated in an orientation session approximately two weeks prior to their first extramural assignment. At that seminar the extramural course director discussed program goals and objectives, provided a general overview about the specific sites and the clientele served, reviewed logistical information about sites, and addressed students’ questions and concerns. During the orientation session students completed a questionnaire that requested the following: gender and race; the names of their two extramural program assignments; experience in dealing with twelve different vulnerable populations; self-assessment of their comfort with treating these groups; and whether they would be willing to treat these groups once they graduate from dental school. The twelve special needs and vulnerable patient groups, in the order that they appeared on the survey, were: low income; frail elderly; homebound; medically complex; mentally compromised; homeless; drug users; other ethnic groups; Title XIX eligible (Medicaid); HIV+/AIDS; jailed; and non-English speaking. Students’ level of comfort was measured using a five-point Likert-style scale (5=no problem; 4=OK; 3=some concern; 2=rather not; and 1=will not treat). Questions concerning students’ prior patient experience with each of the groups and their anticipated willingness to treat each group beyond graduation were categorized dichotomously (Yes/No).

Data from this thirteen-year period were entered into an Excel spreadsheet and then imported to SAS version 9 for analysis. This project was reviewed and approved by the University of Iowa Institutional Review Board.

Skewness of univariate frequency statistics determined that, for statistical analyses, the comfort level variable for each population group needed to be collapsed into a dichotomous variable that consisted of YES, comfortable (which represented no problem and OK) or NO, not completely comfortable (which represented some concern, rather not, and will not treat). This latter group was combined because there were insufficient numbers in each of the three categories to undergo meaningful statistical testing. Moreover, the year since graduation was divided into two categories—less than or equal to five years since graduation (younger) and greater than five years (older)—to simplify the statistical interpretation.

Comfort in treating and future willingness to treat each of the twelve groups were initially compared, using bivariate analysis with either Chi-square or Fisher Exact statistic, for gender, years since graduation, and students’ experience with each group. Logistic regression models were then created for each group when bivariate results demonstrated a p-value less than or equal to 0.1, a liberal value for initial entry into the regression model. If there were no bivariate findings within that population group who met the criterion, then no regression model was developed. Variables were entered into the model using stepwise regression, followed by forward and backward selection methods (p<0.05) to determine the best statistical approach. The possibility of two-way interactions was examined.

Results

Of the 690 senior dental students, 68.2 percent were male and 51.9 percent were in the older (i.e., graduated between 1992 and 1998) of the two cohorts. Table 1⇓ displays the mean and median scores for comfort with treating each group and the percentage of students who were comfortable, had any experience, and willing to treat these patients subsequent to graduation. Mean comfort ratings ranged from a low of 3.6 (HIV+/AIDS) to a high of 4.8 (other ethnic group) on a 5-point scale. When the comfort variable was collapsed into a dichotomous category (i.e., no problem and OK versus some concern, rather not, and will not treat), then the range of students who were comfortable in treating the groups ranged from a low of 47.4 percent (HIV+/AIDS) to 98.4 percent (other ethnic group). There were four groups (homebound, homeless, HIV+/AIDS, and jailed) for which less than one-quarter of the students had some prior experience. Conversely, there was only one group (Title XIX [Medicaid]) in which more than three-quarters of the students had some prior experience. For each patient group, less than 60 percent of the students indicated that they would be willing to treat this group in the future. Only frail elderly and medically complex had a higher percentage of students indicating that they will treat these groups in the future when compared with the percentage of students who had prior patient experience with the same group.

Table 2⇓ displays comfort level with each group by gender, years since graduation, and students’ prior experience in treating each population. Only low income failed to demonstrate any bivariate statistical differences (p<0.1) for inclusion in the logistic regression models. Otherwise, results from bivariate analyses indicated that males perceived more comfort than females with frail elderly, medically complex, mentally compromised, drug users, jail inmates, and non-English speaking patients. There was a split in the bivariate analysis on comfort level based on whether the student was a more recent (younger) or more distant (older) graduate. More recent graduates perceived a greater comfort with drug users (p=0.0026) and HIV+/AIDS patients (p<0.0001), whereas the older student cohort felt more comfortable with homebound (p=0.0014) and other ethnic groups (p=0.0818). With the exception for Title XIX patients, students who had any experience with individuals from the population group felt more comfortable with them.

Similarly, Table 3⇓ shows the perceived future willingness to treat these patient groups with gender, years since graduation, prior experience in treating this population, and students’ comfort level. Females expressed a greater willingness to treat Title XIX patients (p=0.0329) in the future. Among the groups who had statistically significant differences based on the graduation year, the more recent dental graduates perceived a greater willingness to treat these patient groups in the future. Except for the incarcerated, students with any prior experience with each group perceived a greater future willingness to treat these patients. Similarly, when there was statistical significance between willingness to treat in the future and comfort in treating a group (frail elderly [p=0.0785], mentally compromised [p=0.0462], drug user [p=0.0223], HIV+/AIDS [p=0.0012], and non-English speaking patients [p=0.0003]), those who were comfortable with the group expressed a greater willingness to treat that group in the future.

Tables 4⇓ and 5⇓ display the logistic regression models for comfort and willingness to treat, respectively. A regression model was not indicated for the relationship between student comfort and low-income patients because of the lack of statistical significance at the bivariate level. In addition, homeless (p=0.0843), other ethnic groups (p=0.0797), and Title XIX patients (p=0.0531) failed to achieve statistical significance in the regression model. With the exception of the relationship between comfort and the frail elderly group, each of the other models included at least two predictor variables. For the frail elderly, gender was a statistically significant factor in bivariate analysis, but it dropped from the final logistic regression model with a marginally significant p-value (0.0538). Those with prior experience were 2.75 times more likely to be comfortable in treating frail elderly compared to those having no experience.

There were two models in which both graduation year and prior experience influenced student comfort level prior to their extramural rotations. The older student cohort was 1.72 times (1/0.58) more likely to express comfort in treating the homebound as their younger counterparts. Students who had prior experience with the homebound were approximately 2.88 times more likely to feel comfortable with homebound patients. More recent graduates and those with any experience with HIV+/AIDS patients were 1.89 times and 2.51 times, respectively, more likely to be comfortable with this population than the more distant graduates and those without experience with HIV+/AIDS patients.

Five other regression models (medically complex, mentally compromised, drug user, jailed, and non-English speaking) were statistically significant for gender and students’ prior experience. In each model, male students were more likely to express comfort with the affected population, with a range between 1.66 times (non-English speaking) to 3.69 times more likely (jailed). With the exception of comfort with medically complex patients (at 1.48 times more likely) and mentally compromised (at 10.39 times more likely), those with some prior experience had a similar magnitude (2.19 to 2.51 times more likely) to be comfortable with drug users, jailed, and non-English speaking patients.

Mentally compromised patients had the only statistical interaction (i.e., prior experience by gender) among all of the comfort level regression models. There were significant associations between comfort and prior experience for both males (p=0.0034) and females (p<0.0001); however, male students who had no prior experience in treating mentally compromised patients had a higher percentage for comfort (52.3 percent) than did female students who had no experience (36.5 percent).

Only jailed patients failed to achieve the statistical criterion for inclusion in the future willingness to treat regression model. The common predictor variable for each of the other regression models was any prior experience with the population group (Table 5⇑). Students were more likely to be willing to treat frail elderly (2.78 times), homebound (4.65 times), homeless (2.74 times), or drug users (2.58 times) if they had any prior experience with the group compared with those without any experience.

Four other regression models demonstrated statistically significant results for both prior experience and graduation year. When experience with population groups is combined with the other predictor variables in the regression models, there are additional benefits. More recent graduates were 2.93, 3.00, 1.66, and 1.70 times more likely and those with prior experience were 4.03, 3.20, 2.01, and 2.69 times more likely to be willing to treat low-income, medically complex, mentally compromised, and other ethnic group patients, respectively, than the more distant graduates and those without experience.

Regression models for HIV+/AIDS and non-English speaking patients met the statistical criteria for inclusion of student comfort as a predictor variable. In both instances, there was a more positive willingness to treat the groups based on comfort level with these groups. Gender, however, only entered into the model for Title XIX patients. Female students were 1.44 times more likely than their male counterparts to see Title XIX patients in their future practices, while controlling for graduation year and prior experience.

Two future willingness-to-treat regression models contained statistical associations for interaction. For the younger student cohort there was no association between willingness to treat low-income patients and having experience in treating them (p=0.0723), whereas there was a positive association for the older student cohort (p<0.0001) with prior experience in their willingness to treat low-income patients. Similarly, the younger student cohort did not demonstrate a statistical association between willingness to treat medically complex patients and having experience in treating them (p=0.4109); however, there was a statistically significant, positive association for the older student cohort (p<0.0001) with prior experience in their willingness to treat medically complex patients.

Discussion

Twenty-four regression models, each representing either comfort with or future willingness to treat specific special needs or other vulnerable populations, were developed for understanding dental students’ perceptions prior to their extramural rotations.

With four exceptions, experience in treating various populations appeared to have a positive and significant influence for comfort level with these groups. These exceptions were for low-income, homeless, other ethnic group, and Medicaid, which were the groups with the highest level of student comfort (Table 1⇑). When there was a statistically significant difference in the comfort regression models (medically complex, mentally compromised, drug user, jailed, and non-English speaking), males had a higher comfort level prior to the extramural rotations. There were only two regression models that included graduation year as a predictor for student comfort. Controlling for other predictor variables, newer graduates were more comfortable with HIV+/AIDs, whereas the older cohort perceived more comfort with homebound patients.

Perceived future willingness to treat the groups demonstrated some similarities and differences as compared to the perceived comfort statistical models. Except for the incarcerated, students expressed a greater willingness to treat each population group if they had previous experience. Unlike the comfort models, gender only appears in one final model. When holding years since graduation and experience constant, females were 1.44 times more likely to express willingness to treat Title XIX patients in the future. The younger cohort also expressed a greater willingness to treat several of these groups, including low-income, medically complex, mentally compromised, other ethnic groups, Title XIX, and non-English speaking patients. Comfort level with the population groups was only predictive for future willingness to treat with two groups: HIV+/AIDS and non-English speaking.

Several methods have been used to determine health professional students’ attitudes toward traditionally underserved or high-risk groups, such as elderly,^12–16 low income or poor,^17–18 HIV+/AIDS,^19–23 disabled or handicapped,^24–28 mental retardation,¹⁰ homeless,²⁹ or minorities.³⁰ None of these studies provides a complete picture about the constellation of thought and reasoning in determining attitudes. However, educators realize that students bring preconceived attitudes to their extramural experiences, which may be based on purposefully constructed knowledge-based information, acquired indirectly through influences of faculty or other students (“hidden curriculum”), or developed as a result of home environment. These attitudes can exist for a myriad of reasons, although we commonly explore demographic and social influences. While negative attitudes may be very hard to reverse, there are some indications that for at least one disease, HIV+/AIDS, there has been a societal shift in perspectives about care for individuals with HIV+/AIDS.³¹

An objective of extramural programs is to sensitize students to social and cultural factors affecting patient care.³ Educators are hopeful that there will be a substantive positive change in comfort in treating traditionally underserved populations, if it doesn’t already exist. Ultimately, favorable attitudes should convert this comfort into the students’ future willingness to incorporate some of these population groups into their practices. Unfortunately, there is evidence to suggest that the educational system tends to increase cynicism and to decrease humanism and empathy.²⁶ Regardless, efforts to measure attitudes should be initiated and monitored so that progress can be determined concerning any relationship between attitude and behavior of the professional.³²

These findings contribute to our understanding of students’ attitudes about providing care for twelve specific vulnerable and special needs groups. These groups represent patients who are not considered the norm for most private practices and who may not often be encountered by students in dental school clinics. While one would have suspected that prior experience would influence comfort level or future willingness to treat many of these groups, this nonetheless provides empirical findings to support that claim. This is especially true for students who probably have limited exposure to many of these groups.

Possible reasons for why males may feel more comfortable but are not any more likely to express a future willingness to treat these population groups than females are likely to be multifactorial and require further exploration. There are undoubtedly some self-selection criteria that foster the decision to enter dentistry and, thus, may have some influence on students’ comfort or patient selectivity. However, there may be other underlying gender issues that influence patient care attitudes and practice characteristics.³³ Future researchers need to explore the influence of gender upon patient care attitudes in more depth and determine what impact it might have as more female dentists enter the profession.

There are several limitations to these findings. It was up to students to make their own decision about the definitions for “comfort” and “willingness”; thus, there may be latitude in how individuals interpreted these terms. Also, the perceived levels of comfort and willingness to treat these populations may or may not be representative of more fundamental attitudinal issues relating to any or all of these patient population groups. Better scales for investigating the relationship between comfort and willingness to treat need to be implemented in dental education. However, these findings provide some needed insight about core attitudinal issues relating to access to care for many underserved groups.

In conclusion, this study provides baseline information about students’ comfort level for treating various special needs and vulnerable populations prior to extramural rotations. Moreover, this study provides perceptions of these students’ willingness to treat these populations beyond dental school. The findings have implications for curricular development, particularly as students encounter a more diverse population within and external to the dental school environment. There should be course objectives that adequately prepare students so that they better appreciate the populations whom they serve.