Infrastructure for a Community-Based Dental Education Program: Students and Clinics

Early Community Clinic/Practice Rotations

One of the benefits of a community-based rotation is that it gives students the opportunity to experience a segment of the dental care delivery system different from what they have encountered in dental school. Exposure to these settings before the students serve as the clinical provider can facilitate an understanding of the environment, the population served, and the usual services that the student will provide. These early experiences also help to ease the transition from serving as a provider in a dental school setting—where the primary focus is education and training—to the new practice, whether that is a dental clinic within a community health center, a veterans’ medical center, a nursing home, or another setting where the primary focus is patient care. These early rotations also help the student understand the differences between a patient care environment where the student might be expected to treat two or three patients a day and a real world setting where the student is expected to be part of a patient care team treating more patients than at the dental school clinics. These early rotations differ from school to school: they can be purely observational, or the students can actively participate in patient care. The level of students’ participation is based on their level of training and competence. Examples of early community clinic rotations include assisting sessions, providing oral health education, or providing preventive services. Other examples are discipline-specific rotations such as oral surgery or pediatric dentistry outside the dental school clinics at affiliated hospital or community sites prior to comprehensive care clinical rotations.

Cultural Competence Training

The changing demographics of the U.S. population, particularly with respect to race, ethnicity, and age (plus projections for increases in non-Caucasian and elderly populations), will impact the practice of dentistry in the twenty-first century, as will changes in technology. Currently, one out of every five children under age eighteen is the child of an immigrant; by 2030, 40 percent of the U.S. population is likely to be non-Caucasian.¹ According to the U.S. Census Bureau, the number of people aged sixty-five years and older is likely to increase from 40 million today to 56 million in 2020.² About one in eight Americans were classified as elderly in 1994, but about one in five could reach that status by 2030.³

Market forces and health care reform will impact the practice of dentistry more than ever before. Preparing students to treat a diverse population and an underserved population is essential. It is now well recognized that training in cultural competence is an integral part of the dental school curriculum. Cultural competence is the ability to deliver effective dental and medical care to people from different cultures. It is important that the training begin early in dental school and have a strong foundation within the didactic curriculum.

Dental schools have taken varied approaches to incorporating cultural competence training into their curricula. Some schools have developed stand-alone courses, while others have developed modules that are integrated into other courses. Both approaches have their advantages. The stand-alone course serves to highlight the importance of cultural competence and can be easily evaluated. Integration requires a more creative approach to evaluation but underscores the relevance of cultural competence to other curriculum content. In addition, integration makes it more likely that the topic will remain a lasting part of the curriculum. Regardless of the organization of the didactic component, cultural competence skills must be incorporated into the clinical instruction in a dental school clinic. The patients in many community-based rotations are more diverse than the average dental school patient pool; thus, this comprehensive model of didactic and clinical instruction will ensure that the students are well prepared to provide culturally appropriate care. A curriculum in cultural competence must address the domains of awareness, knowledge, and skills.

Cultural awareness includes learning about cultural sensitivity and cultural biases. Cultural knowledge addresses cultural world views, theoretical and conceptual frameworks, cultural exposure, and cultural practice. Some of the educational methods that have been used to teach cultural competence include cognitive processes, such as lectures and readings; self-exploration using discussion groups and journals; experiential learning through community-based education; and skills acquisition with role playing, videotaping, and practicum experience. What each school uses will depend on its curriculum. It can be advantageous to recruit a cultural competence expert to assist in developing and evaluating the selected methodology.

Third-Year Clinical Experiences

Each school designs a community-based clinical experience to complement its own curriculum and then chooses partner sites that will fit this design. In most cases, the partner sites are community health centers whose primary mission is patient care rather than dental education. It is, therefore, important to ensure that the students are adequately prepared to deliver the range of services provided at the partner site. The third year of dental school is important as these clinical experiences provide the foundational skills for the treatment that the students will provide during their CBDE rotations. For example, most community-based sites will support a relatively large number of extractions, so scheduling students’ oral surgery rotations prior to the community-based experience is desirable. Similarly, if the site has a large number of pediatric patients, having a pediatric rotation before the community-based experience may be important. Having some experience in removable prosthodontics and not having to do his or her first denture while on a community rotation is important for a student. Since there may be variation of the services provided at partner sites, schools need to carefully assess the sequencing of their didactic and clinical curricula to ensure that the site directors’ expectations of student preparedness match the students’ skills and experience.

Assignment of Students to Sites

Selection of students for rotation, a critical part of community-based dental education, consists of two steps: 1) selection of the student for rotation, and 2) matching the student to a site. At schools where all senior students must complete a community-based rotation as a graduation requirement, selection of students is based on readiness, completion of third-year competencies, or the amount and quality of clinical work performed. In theory, any student who advances to the senior year is assumed to be ready to go on an externship since he or she should have completed third-year competencies and been promoted to the senior year.

However, student maturity and ability to work independently are also very important. Schools that have multiple rotations or cycles—that is, schools where all students do not go on rotation at the same time or in the same block—often use additional criteria to decide which students will go on rotation early rather than late in the senior year. For example, Boston University, where a fourth-year externship rotation is a graduation requirement, has five ten-week cycles starting in May and ending in April of the following year. To be eligible to participate in the externship rotation, students must be in good academic standing and have successfully completed both their third-year competency exams and the Applied Professional Experience Program (APEX). In the latter part of the third year, the externship, APEX, and clinical program directors assess each student’s skills, clinical experience, knowledge levels, and ability to work independently. Using this information, students are assigned to one of five externship cycles. The better-prepared students are selected for the first cycle.

At schools where only a few students from the senior class go on an externship, the criteria for student selection are different. The selection of students is competitive and often utilizes an application and interview process that assesses students’ skills, knowledge levels, and ability to work independently. In any of the scenarios, studies have found that the better, highly motivated students will be the first to go out on rotation and that their productivity is greater than students who go out on later rotations.⁴

A discussion on assignment of students to community sites is not complete without addressing the length of the community rotations. Each school tailors the length of its community-based educational program to fit within the design of its curriculum, ranging from as little as a week to up to six months or more. The individual rotation generally lasts anywhere from one to twelve weeks. Some schools schedule multiple rotations at various sites, while others have one intensive extramural experience. The rationale for longer rotations includes greater student productivity and the opportunity to perform more complicated procedures requiring multiple appointments. Students and community faculty members report that it takes students about two weeks to become familiar with their new clinical environment. In shorter rotations, therefore, by the time students become familiar with the site and its policies and procedures and are ready to perform independently, the rotation has ended. The exception to this may be programs where students have multiple shorter rotations at the same site: they would spend less time learning clinic protocol during the second rotation.

Our work on clinical productivity at Boston University, comparing students in six-week and ten-week rotations, found that longer externships result in greater clinical productivity and, therefore, more clinical experience.⁵ The mean number of procedures performed each week by ten-week externs was much higher (27.1±10.7) than that of six-week externs (20.3±10.5). Our data also showed that students in the longer rotation are assigned more complex and comprehensive cases. Students in the ten-week externship performed 35 percent more procedures each week than those in the six-week program and 122 percent more procedures over the entire ten weeks. Longer rotations allow completion of the majority of a patient’s treatment plan and build student confidence and time management skills. Additionally, students placed at the sites for a more extended time period have the ability to establish rapport and relationships with their patients. Those on rotation for only a brief period barely have enough time to orient themselves to the site.

Given these factors, it is not surprising that data from the 2003 American Dental Education Association (ADEA) senior survey, which collects (among other data) graduating dental students’ perceptions about their externship experience, shows that students who spent one to two weeks on an externship were less likely to characterize their experience as positive compared to students in three- to five-week rotations.⁶ Students on the shorter rotations were also less likely to report that the experience had a greater impact on them, including an improved ability to care for a diverse population of patients and increased interest in treating underserved populations in their practice.⁷

In general, matching students to the appropriate site is important. The best learning experience occurs when the student and site are a good fit: if the student and site are not a good fit, issues arise that seriously affect the learning experience. Several approaches, many of them student-driven, are utilized by U.S. dental schools to match students to sites. In some schools, a lottery system is used. At others, students are assigned to a rotation. At the University of North Carolina at Chapel Hill, in-state rotations are decided by lottery conducted by the class president. The student picks a number that determines his or her turn to pick the site. Because the school has two rotations, to be fair, those students who get the first pick for the first rotation get the last pick for the second rotation. Some sites are reserved for students who need to stay close to home. At Boston University, students in the spring semester of the third year receive a profile of each site in their externship manual. They then submit their eight top choices, which must be distributed throughout three geographic areas: within Greater Boston; within Massachusetts but more than one hour away; and out of state. The program director uses the rankings and knowledge of both the student and the sites to assign the student. At the University of Iowa, third-year students, after a presentation by the program director, rank order on a scale of 1 to 15 the sites they would like to go to and rank order one of four rotation cycles. The students also indicate whether the site or the rotation cycle is more important to them. Using these factors as guidance, the program director assigns students to sites and rotation cycles.

Transportation and Housing

Since some community-based education sites are located far from the school, commuting to the site every day can be an issue. This is more of an issue for schools with sites across the state or country. It is also an issue for schools with long continuous rotations of ten to twelve weeks since students already have a lease or housing near the dental school and have to find short-term housing at the distant rotation site.

Again, schools use several models with regard to transportation and living arrangements for students assigned to distant sites. Most schools’ policies are that if a student goes out of state, the student covers his or her travel and living expenses, although the living arrangements might be made by the school or site. The most generous arrangements are those in which travel and living arrangements are made by the school and provided to the student at no cost. At the other end of the spectrum are programs at which students pay all their expenses. Some schools, including the University of Colorado Denver, have been able to collaborate with their Area Health Education Centers (AHECs) for arranging and funding housing for students on rotation. At Boston University, students cover their travel for out-of-state rotations, but the site locates and pays for housing that is approved by the school. The University of Iowa uses a mix of these methods: students who go abroad have their travel and living arrangements paid, but at other sites, a wide variety of arrangements exist with some providing transportation and living arrangements and others providing neither.

Prerotation Orientation

To prepare students for a successful rotation, two important steps must be completed: developing a comprehensive operations manual that is distributed to students, and creating a structured orientation.

An externship operations manual that clearly outlines all policies and procedures related to the externship program should be developed for both students and preceptors. It should be updated yearly or more frequently if a change in policy occurs. The operations manual is a critical item when developing a program as it becomes a valuable reference that can be accessed by both faculty and students should questions arise. Additionally, the various manuals remain useful historical documents. Information to have in a manual, at a minimum, includes program objectives, the student placement process, student requirements while on rotation, grading criteria, transportation guidelines, attendance policy, immunization requirements, bloodborne pathogen exposure protocol, and the policy stating that it is mandatory that students maintain their health insurance. The manual can also include a profile for each externship site so that students have information to assist them in determining potential externship sites. These profiles should include the following:

• description of the facility and patient population,

• location and how to access the site by car and public transportation,

• hours that the site is operational,

• a description of the staff (e.g., number of dentists, hygienists, and assistants),

• contact information for both the site and the preceptor,

• types of procedures that the students will routinely perform, and

• housing and meal arrangements.

The manual could also include an in-depth explanation of the assignments students must complete while on rotation, a guide on how to enter clinical data they may need to collect, and sample forms. This manual can be provided to the students as hard copy or online.

The structured prerotation orientation is part of a course and is a requirement at most schools. During the orientation, expectations for all aspects of the rotation should be reviewed along with an explanation of assignments that must be completed, policies, and grading criteria. The orientation can also be an ideal time to collect information to send to the sites (e.g., students’ goals for the rotation and any mandatory criminal record authorization forms) and to remind students to contact their site preceptor to confirm logistics. Many schools also use web-based programs or clinical journals into which the students can record information about the clinical care they provided. The orientation is an ideal time to train students on the data collection method.

Student Information for Sites

Student information sent to the community site faculty is intended to allow the site to determine initial patient load, duration of the appointment, and the types of cases to assign to students. This is particularly important at new sites that have no previous experience in community-based education or hosting students. Most schools send student information to community sites two to four weeks prior to the start of the rotation to allow the site coordinators time to prepare for the student, including scheduling patients for the student. Clinical productivity at the individual student level or aggregate or average data for the class is generally sent. If class information is sent, it is usually presented along these lines: “An average student in the class of 2007 has done eighteen extractions, twenty-four amalgams, eight prophylaxes, and two complete dentures.” Schools that send individual data provide a summary of clinical procedures completed by the student at the dental school. Sometimes student profiles are also provided to the sites. The profiles describe skills, knowledge levels, ability to work independently, and the student’s expectations for the rotation.

Some schools have the students provide a written description of their goals and objectives for the rotation. At the University of Iowa, for example, students fill out a survey of their goals and objectives for the rotation, their comfort level treating patients from various population groups, their previous experience in treating these population groups, and what skills they expect to gain while on rotation. A copy of the results of this survey is sent to the site before the student arrives.

General Site Strategy

Schools that have, or are planning, a community-based education program should develop a site selection strategy taking into consideration the school’s mission, its student body, and its patient mix. Replicating the school environment in a community-based education program is detrimental to the purpose of the program. The best strategy would be to have sites that are different from the school in their environment, treatment philosophies, communities they serve, and patient mix, thereby extending the students’ learning by exposing them to other delivery systems, communities, and types of patients.

Schools adhere to various philosophies in their relationship to the partner sites. Some schools have a myriad of community-based rotation sites and may send a student to a particular site only once every few years. Other schools prefer to have partnerships in which they send students to the site for almost every rotation. The sites should be chosen because they offer opportunities the school feels would be best for a community-based experience. These experiences are usually not focused on learning specific clinical skills, but rather honing patient and time management skills.

Identifying and Selecting Community Sites

The partnership for a community-based rotation can be initiated by either the school or the community site. Most commonly, the school initiates the contact based on the need for sites in a specific geographic location or for a need for students to gain experience providing clinical care for a specific population group. Since sites are most often not private practices, when the school is trying to identify new sites, particularly those out of state, it is often beneficial to contact that state’s dental director and primary care or community health association for recommendations.

There are no universally accepted site selection criteria; however, a school should develop a “wish list” for what it considers an ideal site. The following are some criteria to consider for this wish list:

• accreditation status,

• supportive administration,

• clinical facilities or infrastructure that can accommodate students,

• a wide range of clinical experiences,

• supervision by experienced and motivated practitioners who are interested in teaching students,

• opportunity to practice four-handed dentistry,

• personnel who are CPR-certified and who comply with Occupational Safety and Health Administration (OSHA) regulations, and

• commuting distance from the school, if relevant.

A factor that cannot be emphasized enough when developing the partnership is the preceptor or mentor role of the clinical dental practitioner, including his or her supervisory and educational responsibilities. The clinical teaching model at an externship is different from that of a dental school. At the community site, the preceptor or faculty member is expected to continue to treat patients while he or she supervises students. At a dental school, the faculty member has a supervisory and mentor role only and does not treat patients independently. These discussions should occur before an affiliation agreement is signed. Some schools require that the sites be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or some other accrediting body. Other schools conduct their own site credentialing. In almost all cases, a site visit is required as part of the site selection process. Factors to consider during the visit include the preceptor’s interest in teaching; the preceptor’s expectations and goals for the relationship; the medical director and executive director’s support; whether the site hosts any other students or interns (e.g., dental, medical, nursing); and staffing and staff credentials. It is also important to review records, scheduling, infection control procedures, policies and protocols, longevity and stability of dental staff, number of available operatories, and hours of operation.

Memorandum of Understanding

A memorandum of understanding, or affiliation agreement, is needed to spell out the roles and responsibilities of the two organizations. Once a site is approved, an affiliation agreement is prepared that defines the relationship between the school and the site. The purpose of the affiliation is the education of students and the delivery of services to patients. The agreement should outline institutional governance and management responsibilities; selection, appointment, roles and responsibilities of program directors, faculty, staff, and trainees; evaluation of student and faculty; quality assurance; financial and reimbursement arrangements; liability; and any unique issues affecting the affiliating sites.^8,9 The sections that are highly recommended for a good memorandum of understanding or affiliation agreement are shown in Table 1⇓.

The extramural sites are responsible for patient care, while the school is responsible for defining the educational objectives and for administering the community experience. The agreement recognizes extramural sites as extensions of the school, thus providing liability protection to the students. The sites maintain administrative responsibility for students rotating through their facilities, ensuring that they are in compliance with the rules, standards, and philosophy of both the individual facility and the school, which must be reviewed annually with site directors. Recommended roles of the dental school and the community for a memorandum of understanding to address are shown in Table 2⇓.

Legal Liability

The placement of students at off-site clinical facilities during community-based educational programs puts legal responsibilities on the school with substantial implications as it implies that the dental care provided by students at community sites is approved and supervised by the dental school. Some of these liabilities are similar to those in effect when students are providing patient care in the school’s clinics. The extent of the liabilities depends on the nature and degree of the relationship with the community site. The more involvement with the affiliation and operations of the community site, the greater the liability.

Legal liability as it pertains to community-based dental education may differ from state to state. Institutional tort liability is reported as the largest risk of off-site clinical activities, as students are acting as agents of the dental school.¹⁰ These actions include medical malpractice and discriminatory or defamatory claims. Therefore, preparing the student and matching the student appropriately to the site are essential. As in the dental school environment, physical safety of students while off-site is a concern that is the responsibility of the school. Legal concerns uniquely affecting off-site training and clinics relate to accreditation, ownership of the clinic, student safety and reporting requirements, student records, ownership of medical and dental records, state practice acts, billing for services, malpractice insurance and indemnification, patient care and education such as informing patients that students may deliver care and length of time treatment may take, faculty supervision and their training role, and OSHA issues.¹⁰

Dental schools should seek assistance from their university’s Office of the General Counsel or legal department to review state practice and malpractice acts and develop affiliation agreements. The state’s practice act should be reviewed and adhered to in order to ensure compliance in regard to licensure, supervision, curriculum, and approval requirements. Additionally, malpractice issues, general liability insurance policies, and coverage of students while at community sites should be assessed. If the school is considering community sites outside the state, then practice acts and malpractice issues in those states should be evaluated and followed.