The challenge. The state of Georgia has large unmet dental care needs. The College of Dental Medicine, Georgia Health Sciences University, the state's dental school,* sought to address these needs while revising dental education by expanding opportunities for students to participate in off-campus, community-based clinical rotations.
A focus on need. Carole M. Hanes, DMD, has been on the faculty for more than 25 years. A professor in the Department of Pediatric Dentistry, she is also Associate Dean for Students, Admissions and Alumni. "I knew there were lots of patients in Georgia who needed to be treated and had trouble getting access to care," she says. "I also knew we had dental students who needed to have the opportunity and experience to treat them. It was a dream of mine to marry those two."
Connie L. Drisko, DDS, who became dean of the College of Dental Medicine in 2003, found the need in Georgia to be "profound." She wanted to increase access to care, but felt it "was just as important" to strengthen dental students' cultural competency. Drisko noted that Georgia has one of the highest Black populations of any state and a fast-growing Hispanic population. "It was really important to not only increase the diversity in our classes but also to produce graduates who would feel comfortable with and go back to those populations to work."
Under Drisko's leadership, the College of Dental Medicine began working on systematically changing the dental education program, including expanding community-based clinical rotations. A three-year grant from the Health Resources and Services Administration (HRSA) at the U.S. Department of Health and Human Services supported the 2006 initiation of the school's community-based dental education program.
The program began with six clinics hosting senior students for one two-week period. Local Area Health Education Centers helped to provide housing and acclimate students to the community. (These centers bring resources of academic medicine to address community health needs and strive to develop a health professions workforce committed to underserved populations.)
Connecting with RWJF's Dental Pipeline Program. As a participant in Round 2 of the Robert Wood Johnson Foundation (RWJF) national program Pipeline, Profession and Practice: Community-Based Dental Education, known as the Dental Pipeline Program, the Medical College of Georgia School of Dentistry expanded its community-based clinic program begun under the HRSA grant. From 2008 to 2010, the dental school increased the amount of time students spend in community-based dental clinics from two weeks to six weeks, and thus, the number of patients who received dental care. The expansion has made "a huge difference in our state and in the number of students that have gone on to take jobs in public health," says Drisko.
Multi-layered benefits. The benefits resulting from the expansion and institutionalization of the community-based education program are many. "It had a tremendous effect on the culture of the school and changed people's perceptions of how beneficial it is to get out in the real world and get exposure to treating all sorts of populations," says Drisko. By 2012 (after the grant, which ended in 2010), students were completing about 15,000 patient procedures annually in 25 clinics, compared with about 5,000 procedures in eight clinics before the grant, according to Drisko.
Hanes cites the impact on student confidence. "Away from the school environment students see that they are capable of decision making and problem solving. They're more independent in these sites at a time when they're ready for that. Their confidence really grows." Students also have more opportunity to do more of certain types of procedures, especially endodontics, oral surgery, and pediatric dentistry, than is available at the dental school clinics.
The experience also improves students' cultural sensitivity. "Their knowledge about the problems with access to care and the unmet need that exist in Georgia grows," say Hanes, "as does their sensitivity to different populations."
This, in turn, has an impact on students' interest in returning to these communities to practice after they graduate. "They now know what to expect when they're going into practice," says Ketarya D.H. Dent, MPH, CHES, director of Community-Based Education. Even if they do not want to work full time in public health they are more likely to consider volunteering their time. "We have a variety of clinics where dentists with private practices volunteer their time and the students see that this works."
Benefits are also evident school-wide. Productivity in the senior clinic at the school has risen since students have been spending more time in the community settings, which to Drisko "means that they have built their skills and they are faster and better when they get back."
As evidence of the school's level of commitment to the program, Drisko cites the new building, designed to hold only 80 senior students while the school plans to grow to 100 students per class by 2016. "We fully committed to having 20 percent of our senior students out in the community at all times," she says—which the new building necessitates.
"Without RWJF's support we would not have been able to do nearly as much as we have," Drisko acknowledges. "Now our biggest challenge is to make sure we can keep things going." Helping with that effort is a renewable three-year contract from HRSA, received in 2009, to continue the program and expand its efforts into other areas. Recently, the College of Dental Medicine has been awarded a renewable HRSA grant for 2012 through 2015.
Spreading lessons on how to succeed. Hanes' number one piece of advice is to "have a dean who is very supportive from the start. That has a lot to do with it—not only with the workings of the program, but with faculty perceptions of the program and the way it's presented across the state."
Faculty buy-in is also critical. Faculty at the Georgia Health Sciences University College of Dental Medicine were concerned about students' ability to meet graduation requirements off-campus and retain school-structured standards during the community experience. Associate Dean for Patient Services W. Frank Caughman, DMD, a member of the clinical faculty, took charge of the establishment of procedural standards with the off-campus community faculty and conducted site visits at the community facilities. "That lent credibility to the off-site program that was very important to the faculty as we were growing the program," says Hanes. And good documentation of procedures completed in the community clinics increases faculty willingness to award credit for work done there.
The support of other stakeholders is very helpful as well. Meetings about the community-based education program include staff from the community sites and representatives of the local Area Health Education Centers continue to help with housing and "go out of their way to be supportive and involved," says Hanes.
"Be prepared to have matching funds," advises Drisko. "A lot of grants expect it. The school has to put out a little money to get these programs started. But it hasn't had a negative impact on our clinic income since the students are so productive when they return."
To address the long-term issue of access to care, selection of students admitted to the dental school is very important, says Drisko. "We have guidelines that give a little extra consideration to applicants from health shortage areas. We felt that the more people we recruited from those areas, the better the chance of them going back there to practice. Now we have grown from about 12 percent of our classes being from health shortage areas to over 60 percent in the class accepted most recently."
RWJF perspective. The Dental Pipeline Program helped improve access to dental care for underserved populations from 2001 to 2010. The program funded dental schools to increase the diversity of dentists trained to deliver this care and enhance student exposure to community-based practices treating medically disadvantaged patients.
Round 1 funded 15 funded dental schools, which all developed community-based clinical education programs to provide care to those in need. Most schools also increased recruitment and retention of underrepresented minority and low-income students. Round 2 funded eight additional dental schools: four focused on community-based education and four focused on increasing minority and low-income student recruitment. The California Endowment funded dental schools in California (four in Round 1 and five in Round 2).
"The hard work and collective commitment of all the program directors and deans within the Dental Pipeline Program substantially contributed to the program's success," says RWJF Program Officer Denise Davis, DrPH, MPA. "Through collaborative learning about best practices, all dental schools were able to highlight their unique strengths and share their extensive expertise.
"An example is the Medical College of Georgia School of Dentistry's expanded community-based clinical rotations. Dr. Drisko and Dr. Hanes increased student off-site clinical rotation time, thus enhancing student field experience and interest in community dentistry. These important program changes have contributed to increased service provision to underserved areas in Georgia, which is a huge accomplishment. The school exemplifies the kind of solutions to dental access that the Dental Pipeline Program was created to advance."
* It was renamed the Georgia Regents University College of Dental Medicine in January 2013.
- Evaluating the Dental Pipeline Program: Recruiting Minorities and Promoting Community-Based Dental Education
- Reforming Dental Workforce Education and Practice in the USA
- Reflections on the Dental Pipeline Program’s Efforts Regarding Underrepresented Minority Dental Students
- Special Supplement of the Journal of Dental Education Highlights RWJF's Dental Pipeline Program
- Infrastructure for a Community-Based Dental Education Program
- Organization and Management of Community-Based Dental Education Programs
- Underrepresented Minority Dental Student Recruitment and Enrollment Programs