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Abstract
Community-based dental education (CBDE) allows dental students to be immersed in community settings and provide care to populations that are underserved. Exposure to those groups during training may impact provider attitudes, which may be strengthened by supporting students’ reflection and exploration of their own attitudes. The aim of this study was to describe the implementation and preliminary results of a pilot longitudinal reflection curriculum integrated into a community-based clinical experience (CBCE) for senior dental students at one U.S. dental school and to report the impact of the reflection curriculum and CBCE on student experiences with populations that are underserved. In academic year 2015–16, all 35 senior dental students at one U.S. dental school were invited to complete an 11-item survey before and after completing a 12-week CBCE with integrated, longitudinal online reflections. Students received feedback from a faculty member after each reflection. All 35 students completed the survey, for a 100% response rate. After the CBCE, the students reported improved clinical efficiency and increased confidence in treatment planning and in treating dental emergencies and dentally anxious patients. They also reported improved understanding of the structure and relevance of community health centers, the role of different health care team members, and the impact of health policy. There was no significant difference in future plans to work with groups that are underserved. These results suggest that the CBCE and reflection curriculum had a positive impact on the students’ clinical confidence as well as expanding their understanding of the broader oral health care delivery system. To address persistent oral health disparities, dental schools should continue to adopt CBDE programming that will prepare providers to effectively care for populations that are underserved.
- dental education
- community-based dental education
- attitude of health personnel
- cultural competence
- health care disparities
- access to health care
- dental care delivery
- health policy
People from underserved communities are at highest risk of poor oral health.1 Training dentists to provide culturally competent care to patients in diverse communities is integral to reducing oral health disparities, and Commission on Dental Accreditation (CODA) standards mandate that dental schools train culturally competent dentists.2 A key component of a diverse, patient-centered dental education is engaging dental students in community-based dental education (CBDE). Community training adds richness to students’ clinical learning, exposes students to diverse patient populations, and immerses them in the infrastructural and social challenges of safety-net care. For these reasons, the CODA standards also require that dental schools provide students with opportunities for service-learning and CBDE.
Studies have found that health professions students involved in CBDE while in training were more likely to provide care to populations that are underserved after graduating.3,4 However, without adequate support, students may feel unprepared to treat relatively challenging populations in resource-limited environments.5 Reflection—defined as the process of integrating experience and knowledge to identify learning needs, cultivate professional identity, and form new knowledge links—serves as one tool for student development.6 Written reflections add academic rigor to CBDE and provide dental educators with information about students’ experiences in the community that might not otherwise be apparent. Written reflections help students increase awareness of their performance in community health settings, raise their ability to question preconceived assumptions, and better understand how others influence their lives throughout the course of their training.7,8 Educational researchers have described two types of reflections: reflection-in-action, in which the experience is instructive, and reflection-on-action, in which the reflection process following the experience is itself instructive.9 Both forms of reflection contribute to professional identity development, as they allow individuals to process their past action and use this awareness to shape their future actions. Reflective assignments have been successfully integrated into preclinical7 and clinical10 dental curricula; however, many written reflection assignments occur only upon the conclusion of a clinical experience that can span weeks or even months.11,12 The aim of this study was to describe the implementation and preliminary results of a pilot longitudinal reflection curriculum integrated into a community-based clinical experience (CBCE) for senior dental students at one U.S. dental school and to report the impact of the reflection curriculum and CBCE on student experiences with populations that are underserved.
Methods
This study was determined to be exempt by the Harvard University Institutional Review Board (IRB15-4021). All students at the Harvard School of Dental Medicine are required to complete a 12-week CBCE in a community health center during their fourth and final year of dental school. Students are assigned to the same site for all 12 weeks and do not have scheduled obligations at the dental school during this time to ensure immersion in the externship experience. Students are assigned to one of 12 sites for the duration of their experience. Ten of the 12 sites are Federally Qualified Health Centers (FQHCs), one is a Department of Veterans Affairs (VA) clinic, and one is a rural free clinic. Ten sites are in the greater Boston area and can be reached by public transportation, while one site is in rural Vermont and another is on Cape Cod; the latter two sites offer free housing for student externs. Students are assigned to one of three rotations for their experience: August–October, November–January, or February–April. During the CBCE, students are responsible for providing direct clinical care for patients in the community under the supervision of licensed dentists.
The reflection curriculum was developed as a longitudinal exercise intended to complement students’ clinical experiences and increase their critical thinking and public health competence. The entirety of the curriculum was delivered through the e-learning platform Foliotek, Inc. (Columbia, MO, USA), which students use to submit all coursework for evaluation. The curriculum was divided into six biweekly units, each building on the previous unit and the students’ growing clinical competence (Table 1). Each unit consisted of one to three assigned readings selected from narrative nonfiction13,14 and scholarly publications.15,16 At the end of each two-week block, students were prompted to compose a directed reflection of approximately 300 words related to the theme of the unit. After each submission, students received a personalized response to their reflection from the core faculty member. Students who failed to submit a reflection on time received daily reminders via email until they completed the reflection; no student submitted a reflection more than one week after the deadline.
Reflection curriculum units with key themes and related Commission on Dental Accreditation (CODA) standards
For the study, in academic year 2015–16, students were prompted to complete an identical survey before embarking on their CBCE and within five days of completing their CBCE and the reflection curriculum. As students participated in the CBCE in three separate blocks over the course of the academic year, it was distributed three times to one third of the class each time: in August, October, and February. The survey explored students’ perceived confidence in patient management, their awareness of the function of community health centers and dental insurance, and their intent to work with underserved groups in the future. The survey was accessed through the same e-learning platform through which students completed the reflection curriculum. In addition to the online survey, curriculum feedback was obtained during an in-person feedback meeting with the core faculty.
Upon completion by the entire graduating class, survey results were de-identified and aggregated. Mean responses and standard deviations were recorded for each of the survey’s 11 items. Differences in mean responses before and after completion of the CBCE were calculated. A paired Student’s t-test was used to calculate significance (p<0.05 significance).
To evaluate progression of student thought over the course of the CBCE, a qualitative analysis of the first and final two reflection assignments was undertaken. These reflections guided students first to reflect on their primary concerns and feelings of excitement for the experience, the biggest problems they perceived at their clinical site, and their most rewarding experience in the CBCE. These responses were chosen as they represented distinct themes, were assigned early and late in the experience, and required the most free-text entry from students. Responses were de-identified and compiled in PDF format. They were reviewed and coded by two authors to identify common themes. Reliability was achieved through independent review of the responses and discussion between the reviewers to reach consensus on identified themes and subthemes. All 35 assignments were reviewed for themes and included in the analysis. All assignments had a requirement of at least 150 words; there was no noted decrease in the length or quality of assignments at the beginning and end of the CBCE nor between rotation periods.
Results
Survey Results
All 35 students in the Class of 2016 participated in the 12-week CBCE. Clinic locations and the number of students in each clinic setting are shown in Table 2. The majority of the students (n=24) were placed at an FQHC in the greater Boston area. In addition, small groups of students were placed at an urban FQHC serving the city’s homeless population (n=4), a rural free clinic in northern New England (n=3), and a VA clinic (n=3). One student participated at a rural FQHC on Cape Cod; this was the only site where students in previous classes had not participated in the past. All other sites were accessible by public transit within the city.
Setting of student community-based clinical experiences with number of students at each type of site
All 35 students completed the survey, for a 100% response rate. The pre-experience survey was completed no more than one week before the start of the clinical experience. The post-experience survey was completed no more than one month after the conclusion of the clinical experience. Students were asked to indicate their agreement with 11 statements on a Likert scale from 1=strongly disagree to 5=strongly agree. Average scores on the pre and post surveys are shown in Table 3. There was no significant difference in student responses among the three rotation groups (summer-fall, fall-winter, and winter-spring).
Survey responses before and after completion of 12-week community-based clinical experience (CBCE)
On average, the students reported greater agreement with all statements after completion of the CBCE (Table 3). After the experience, no students strongly disagreed with any of the survey items. The greatest improvements noted after the CBCE were in students’ clinical confidence and understanding of the social relevance of community health centers. The students reported increased clinical confidence both generally and when working with special patient populations. Prior to beginning the CBCE, the students reported a mean agreement of 2.46±0.82 with the statement “I feel confident as a clinician in terms of efficiency, clinical skills, and competence.” After the CBCE, they reported a mean agreement of 1.77±0.55 (p<0.001). Before their CBCE, students reported a mean agreement of 2.03±0.66 with the statement “I feel competent in developing different treatment plans for my patient,” which improved to an agreement of 1.83±0.51 (p=0.025). However, there was not a significant change in student-reported comfort regarding treatment sequencing, payment, and patient responsibilities (pre 2.31±0.83, post 2.14±0.81; p=0.162). The students reported improved confidence in managing dental emergencies (pre 2.97±0.86, post 2.09±0.74; p<0.001) and anxious or fearful dental patients (pre 2.23±0.77, post 1.77±0.65; p<0.001). There was a slight increase in student-reported confidence in treating patients with special health care needs (pre 3.03±0.82, post 2.77±0.91; p=0.076).
The students also reported an improved understanding of the dental health care system after completing their experience. Students were significantly more likely to agree that they understood the organization and function of community health centers (pre 3.09±0.85, post 2.06±0.73; p<0.001) and their social relevance (pre 2.47±0.71, post 1.77±0.65; p<0.001), as well as how different members of the patient care team collaborate (pre 2.40±0.69, post 1.89±0.68; p=0.002). After the experience, students were significantly more likely to agree that they understood how health policy and insurance affect their patients (pre 2.31±0.90, post 1.97±0.66; p=0.028).
There was an increase in students’ interest in incorporating community health and outreach into their future practice, although the difference was not significant (pre 2.17±0.75, post 2.00±0.80; p=0.113). Only two students disagreed that they planned to be a provider for populations that are underserved, and ten students strongly agreed that they planned to be a provider for these groups.
Reflections Results
Three themes emerged as the primary concerns of students prior to beginning their CBCE. These were clinical efficacy (17/35 responses), struggling to connect with patients (12/35), and personal well-being (6/35). Students described concerns that they would be too slow for the demands of the clinic or that they would be unable to provide treatment of sufficient quality. Students also described concerns about communication barriers due to short appointment times, language barriers, or lack of extended relationships with patients. Finally, students were also concerned about personal safety in lower income neighborhoods, risk of infectious disease transmission, and stress.
When students commented on what they were excited about in their rotations, the three most common themes were working in the “real world” (12/35), being able to help others (15/35), and improving their clinical efficiency (20/35). Students perceived the CBCE as their first opportunity to see what dental practice was like outside the educational setting and reported believing the intensive experience would improve their clinical abilities and allow them to perform high-quality care at a faster pace. One student noted, “I am excited to practice dentistry more closely to how it happens in real life. School is a bit of a bubble. This is more real.” Student were also looking forward to caring for patients in need.
Two weeks before the conclusion of their CBCE, the students were asked to reflect on the biggest problems they noted at their clinical site. Across the sites, the most common themes noted were coping with limited resources (22/35), witnessing challenges faced by patients (15/35), and wanting more time to connect with patients (15/35). The students found it difficult to take on a clinical role in a resource-limited setting, especially given the severity of dental need they noted among patients. They noted that the clinic patients had more severe decay than patients at the dental school clinic (3/35) and had lower oral health literacy (5/35) or a substance use disorder (4/35), which further compromised their care. As one student wrote, “I felt guilty that a majority of patients were locked in this cycle of recurring disease and substandard care, with no idea on how to prevent it at all.”
Finally, students were asked what was most rewarding during their rotation. Two common themes emerged in these reflections: building meaningful relationships with patients (27/35) and achieving clinical competence (14/35). Almost every student described a personal interaction as the most rewarding experience during the rotation. A student noted, “It was very rewarding to fix someone’s pain, infection, and to improve esthetics all at the same time,” and another commented that if the students “worked hard and treated [patients] with respect, [they] got the same respect back from them with time.” One student even wrote of a touching encounter with a young patient and his mother: “She said that [the patient] was pretending to be a doctor the other day giving mom and dad imaginary shots. When she asked him what he was doing, he told her he was pretending to be me. I don’t want to speak too soon, but maybe his experience will push him to pursue a career in health care in the future.”
Discussion
Community-based clinical experiences can enrich the exposure of dental students to a variety of populations and can be a critical component of predoctoral dental education. Community-based service-learning has been shown to increase students’ clinical confidence and productivity,17–19 as well as student-reported comfort in treating vulnerable groups they served during the clinical experience.20–22
However, not all community opportunities are equally impactful. CODA standard 2–25 specifies only that dental schools must “make available opportunities and encourage students to engage in service-learning experiences and/or community-based learning experiences” and does not make them mandatory.2 Service-learning is simply a service project in the community with some educational aspect (e.g., visiting an elementary school to provide oral health information to students, followed by reflection on the experience), and the length of a community-based clinical rotation may range from a few days to several months.2,23–26 Also, experience in treating specific populations may not translate to students’ comfort in treating other vulnerable groups, and students’ negative expectations about working in lower resourced settings, such as higher failed appointment rates and limited supplies, may actually be borne out during the rotation.12,20 As dentists who participated in better structured CBCEs have been found to be more likely to treat patients from underserved groups in practice, ensuring that students have positive experiences is critically important to producing a dental workforce that can address oral health disparities.27
Reflection can serve as one mechanism to support students’ growth in the community setting. Structured reflection allows practitioners-in-training to better understand their clinical decision making, explore the structure of the oral health care system in which they work, and articulate their approach to challenging interactions.10,11,28 Reflection skills can benefit even experienced practitioners, enabling lifelong learning.6 While dental schools seek to produce graduates who consider oral health a vital component of general health, graduates should also remember that an oral cavity in need of treatment is part of a patient who may consider a visit to the dentist as a last resort.
Reflective exercises have been implemented to increase cultural competence among both clinical and preclinical dental students.7,11 It has also been a successful component of community-based education at several dental schools.10,12,29 However, most of those reflections occurred at a single point in time, usually upon completion of the experience, rather than over the course of the training period.
Our reflection curriculum was integrated throughout the CBCE, intended to model the continuous, iterative process of successful reflective practice.6 Assignments guided students through an understanding of their clinical setting from the personal (“What are you nervous about as you start this experience?”) to the patient-focused (“Describe a difficult experience from the perception of your patient.”) to the systemic (“What is the biggest problem you see in your clinical site?”). An additional benefit of these embedded reflection assignments was that they provided a continuous link to the dental school for students who may not be physically present, allowing students to feel supported by their educational institution throughout their clinical learning.
Trainee-generated portfolios have become popular in health professions education as they allow critical reflection to be integrated into the process of documenting clinical and academic activities.30 In addition to prompting self-assessment, portfolios have also been found to support competency-based evaluation of trainee performance in medical education.31 Online portfolios, known as ePortfolios, provide additional flexibility as students may access them remotely or even on a mobile device, and faculty may provide real-time feedback to enhance student learning.32 Previous studies have shown that ePortfolios’ capacity for reflection and the utility of feedback provided can vary based on whether students and faculty members perceive the ePortfolio to be accessible, easy-to-use, and requiring an appropriate amount of time to complete.33,34 During a feedback session following their experience, students in our study indicated that receiving prompt, personalized responses to their reflections from a faculty member was extremely valuable, as the students felt their opinions were validated and anecdotally indicated they put a higher level of effort into their reflections knowing they were “being heard.” Additionally, required reflections were separated into no more than two fields and were intended to be 300–500 words in length, which may result in higher completion rates and student-reported satisfaction than forms with more entry fields.35
In our survey, students did not demonstrate a significant change in their reported plans to work with patients in underserved groups in future practice. Troublingly, five students reported they were less likely to work with underserved groups after the CBCE compared to before it began. This finding suggests that students may have lacked sufficient support or preparation to thrive during the CBCE and thus ended the experiences with a more negative view of community practice. Learning from these students and working with on-site faculty to ensure a high-quality experience for all students may reverse this finding. Unfortunately, this pattern is consistent with findings across the health professions, including dentistry, that student attitudes towards patients from underserved groups as well as general empathy declined over the course of training.36–40 Past research has found only transient improvements in dental students’ attitudes towards these groups after completing CBCEs.41 However, research from other health professions has indicated that community-based experiences may still alter students’ perceptions for the better. Most notably, students who participated in cultural competence training, who attended schools with a mission focused on service, or who participated in clinical administration (for example, by working in a student-run clinic) were all more likely to have significant gains in attitudes towards underserved populations.3,42 These findings support that CBCEs alone are not enough; rather, student immersion in safety net settings where they are prepared, empowered, and supported by their dental school is necessary for the impact of CBCEs to stretch beyond mere clinical productivity and have an effect on their practice patterns.
This study had several limitations. Given the small sample size, analysis of significant variations in survey response between students serving at different clinical sites was not possible. As only one graduating class has completed the reflection curriculum, potential inter-class variability in attitudes towards the experience and the reflection curriculum itself would not be apparent. Due to the small sample size, the impact of individual clinical sites on student attitudes could not be assessed. Given that well-structured experiences are linked to improved provider attitudes, this information could be especially important in identifying sites where support and training could be improved.27 In our continued analysis of subsequent classes, through revision of our survey, and by evaluating alumni career choices, we hope to better understand the impact of the reflection curriculum on externship experiences. An additional limitation is the relatively narrow geographic scope of our clinical sites. As Medicaid covers a different scope of oral health services in different states and oral health access issues may vary dramatically in rural versus urban locations, a more diverse group of clinical sites may result in very different student attitudes.1 An online reflection curriculum that can reach students throughout their clinical experience regardless of location presents one possibility for curricular innovation that will produce a generation of culturally competent providers.
Conclusion
As community-based clinical rotations become more widespread, dental schools must ensure that students are given opportunities for growth and reflection that will empower them to serve those who currently struggle to obtain oral health care. Curriculum development presents an opportunity to prompt student self-assessment, provide feedback, and enhance reflection, leading to professional development. In combination with a CBCE, this pilot study contributed to improved student understanding of the role of community health centers and health policy, as well as improved clinical confidence, although student intention to work with the underserved was not affected. Cultivating student empathy and desire to work with populations that are underserved throughout dental education will be critical to developing a culturally competent dental workforce that can serve the needs of the U.S. population.
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