ADEA CCI Liaison Ledger

Changing Times for Community-Based Dental Education

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Howard L. Bailit, D.M.D., Ph.D., Professor Emeritus, Department of Community Medicine and Health Care, University of Connecticut Health Center and Co-Director of the Dental Pipeline Program

In his famous ballad, Bob Dylan sang, "the times, they are a-changin." This is certainly true about dental education. More schools have senior students spend time in community clinics and in private practice providing care to underserved patients, with just over half requiring five or more weeks of such experience. Based on my experience working with dental schools across the country through the Dental Pipeline Program, I see three principal factors-financial, educational, and community service-driving this."

The Financial Factor

With the decline in state funding, most public schools face serious financial challenges. Private schools are also under financial stress, because many cannot continue to increase tuition 5 to 10% annually and hope to recruit a financially diverse pool of students. Some schools deal with these financial challenges by reducing the cost of clinical education through community-based education. Several new dental schools have financial models built on students serving in the community 70 or more days per year. This saves substantially on construction costs, since fewer operatories are needed per student, and all schools that employ community-based education save money operationally, both in the short and long terms.

Evidence from Boston University* suggests that students are more productive when they return from their community experiences, so in the short term collected revenues per student remain the same or increase. Some schools also found that in the long term community education can result in substantial savings if schools reduce the number of chairs per student. This can occur by increasing enrollment or reducing the number of chairs. Based on 2009 data from eight schools participating in a Dental Pipeline study, senior students averaged about $20,000 per chair in collected revenues, but generated around $60,000 per chair in clinic expenses (faculty, staff, supplies, etc.). With an average loss of $40,000 per chair, schools with one chair per senior student had much larger losses than schools with 0.5 chairs per student.

Interestingly, dental education is now following other health professions (medicine, pharmacy, and nursing), which already train students in clinical facilities that schools do not own or manage. With rapid expansion of the dental safety net system now under way as part of health care reform, dental schools will have many more opportunities to partner with clinical facilities for dental student and resident rotations.

The Educational Factor

There is growing evidence that students are much more productive in community settings than in dental school clinics. The primary reason is that dental school clinics operate as teaching laboratories, i.e., their primary objective is education. The care that patients receive is a secondary outcome. Within this educational setting, faculty do not provide care to patients while they supervise students, and students generally treat one patient per three-hour session and provide relatively few services per visit. This lack of productivity is largely because students do not have access to dental assistants. They must wait for instructors (who usually manage six to seven other students) to check each major treatment step, and they have to wait in line to obtain sterilized equipment and supplies. This system necessitates several long visits to complete patient treatment plans. To attract patients under these conditions, schools usually set student patient fees at 50% of usual and customary fees charged by private practitioners.

The primary goal of community clinics is patient care, not education, and therefore they utilize a different teaching model. Usually one community clinic dentist supervises one student but continues to provide care to his or her own panel of patients. This system works well when students are assigned to one clinic for three or more consecutive weeks. Despite a different teaching model and focus at community clinics, students receive more than adequate instruction time in this teaching model because community clinic dentists only supervise one student at a time.

Community clinics are also able to provide students with full-time dental assistants and other administrative staff. In this setting students see seven to 10 patients a day and rapidly gain the skills, knowledge, and confidence that come from caring for many patients. Several studies indicate that students have a strong preference for this form of clinical education.

The Community Service Factor

As already noted, the number of procedures provided per unit of time differs substantially between dental school and community clinics. The magnitude of these differences is best captured in a comment by a senior student at a Dental Pipeline school. She said that before her community rotation she had performed one two-surface amalgam. In her six-week community clinic experience, she completed 160 amalgams.

Because students are so productive in community facilities, large numbers of underserved patients receive care. This provides schools with the opportunity to have a significant impact on decreasing access disparities in their local communities and, more importantly, to be recognized by their communities and universities for these contributions. This issue is becoming more important as schools compete for public and private resources in this period of financial stress. Clearly, they are much better positioned to argue the merits of their case if they have strong political support from their local communities.

In addition to the direct provision of care, schools have another way to reduce access disparities. Many Dental Pipeline schools reported that once students spend time in community clinics, a small but significant percentage of them decide to seek careers in these settings. Dr. John McFarland, the Dental Director of a group of community clinics in Colorado, told me that a large percentage of his full-time dentists rotated through his clinics as students. Thus, these community experiences do influence the career choices of some students.

To conclude, improved school finances, better education, and community service are all compelling reasons to expand the use of community-based dental education. As this trend continues, the new challenge is for schools to work with their community partners to improve the operations of these service-learning programs. This new "distributed" education model requires organizational structures and operational methods that differ from those employed in traditional dental school clinics. I have no doubt that clinical dental educators will meet this challenge and that community-based dental education will continue to thrive.

*Henshaw MM, Frankl CS, Bolden AJ, et al. Community-based dental education at Boston University Goldman School of Dental Medicine. J Dent Educ. 1999 Dec;63(12):933-7. Not available online.

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