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In this month’s letter, ADEA Executive Director Dr. Rick Valachovic shares exciting news out of Ann Arbor and Chicago and describes a grant opportunity for schools that are ready to engage more deeply in community-based education.

Reaping the Rewards of Community-Based Education

Dr. Richard ValachovicThe new Commission on Dental Accreditation (CODA) predoctoral standards for dental education programs require dental schools to offer students with opportunities to work in community settings, and a 2009 American Dental Education Association (ADEA) survey of dental school curricula indicates that most of our schools are on track to meet that goal. The 2009 survey is old news, but the more recent accomplishments of individual schools that have made major commitments to community-based education are both newsworthy and inspiring.

The experience of our colleagues in Ann Arbor and Chicago strongly suggests that there is a workable community-based education model out there for every school and every partner seeking collaboration.

The CODA standards view community-based education as a means to develop a culturally competent workforce with an appreciation for the value of community service. That development is happening for sure. On a select few campuses, community-based education is transcending those initial goals and creating long-term benefits for students, schools, universities, and the community.

If you had visited the University of Michigan (U-M) School of Dentistry in 2006, you would have found a three-week, community-based education program that placed students at three federally qualified health centers (FQHCs). It was successful as far as it went, but six years later, U-M’s program has expanded beyond anyone’s wildest dreams. Students now experience FQHCs, tribal clinics, private practices, and public health settings over the course of 10 weeks at 27 different sites throughout the state.

Dr. Wilhelm (Bill) A. Piskorowski, Clinical Associate Professor and Director, Community Outreach Programs, is something of a “Johnny Appleseed,” eagerly sowing the seeds of U-M’s community-based education partnerships throughout Michigan since he joined the dental school faculty in 2006. At that time, U-M’s community-based education program relied on a grant that was about to expire. In an effort to replace those funds with more predictable and diversified sources of financial support, Bill developed a revenue-sharing contract with the program’s affiliated FQHC. That financial arrangement has since been adopted by U-M’s other community-based education partners, creating a thriving program that is also financially self-sustaining.

The community of Traverse City in the northern part of lower Michigan provides a microcosm of what U-M has accomplished. The largely rural area is one of the nation’s leading cherry producers and attracts a large number of seasonal workers. Dr. Robert A. Bagramian, founder of U-M’s Dental Public Health Program, started bringing students to the area 40 years ago to take part in a summer program for the children of those workers.

Today, the clinic that hosted that program has an FQHC designation, and U-M places two students there every week year-round to serve the general population. Dental students also have rotations at a tribal clinic 20 miles to the north and provide charitable care to Traverse City patients thanks to a novel partnership between the dental school, the city’s public health department, and the area’s private practitioners.

Last year, Bill approached the local Resort District Dental Society, one of the American Dental Association’s component organizations (these typically provide charitable care as part of their activities), and invited its members to become preceptors for U-M students. The response was overwhelming. Not only did 16 dentists sign on, two of them volunteered their offices as sites for oral surgery and general dentistry.

“This is one of the most giving local component societies I’ve ever met,” Bill told me. “They take four of our students three days a month to provide free care to the people that fall between the cracks. I think the Society did 129 extractions in one day with the help of our students and then spent two more days providing those patients with restorative care. It’s been amazing.”

The Traverse City Health Department, which already relied on volunteers to provide dental care for the area’s poor and uninsured patients, is the third leg of this collaboration, triaging and referring patients for care, and handling the program’s finances.

This arrangement is exceptional in and of itself, but the financial model is especially surprising. Everyone supplies labor free of charge, and the health department picks up the cost of overhead, including student housing and transportation. Overhead is calculated at 15% of the fee schedule of one of the state’s widely accepted insurers. Where does the health department come up with the money? The two dental hygienists who oversee the program have created a pay-it-forward model. Charitable organizations provide the department with grants to fund the program, and patients who receive free care provide something unusual in return: four hours of volunteer service to the charities for every one hundred dollars of treatment.

It’s easy to see that community-based education is benefiting Traverse City and other Michigan communities, but I wanted a sense of how community-based education is impacting U-M’s students and the university itself. I turned to Dr. Peter J. Polverini, Dean of the University of Michigan School of Dentistry. He told me U-M decided to rethink its community-based education program about a year after he became Dean.

“We wanted to transition from a place where you go out to provide care to a place where you become more fully engaged in the community, you understand the experience, and you reflect on that experience. Students really get to see the difficulties that most people have in the community, and when they come back to the dental school, many of them have literally had an epiphany.”

The number of U-M students who choose to work in community clinics upon graduation confirms this high level of engagement. Prior to the implementation of the community-based education program, less than 2% of graduates made this career choice. In 2005, when students began spending three weeks in community-based education, that percentage more than tripled. It has continued to rise in tandem with increases in the number of weeks U-M students spend in the community. (See the May 1, 2012, issue of the Journal of Dental Education for details.) U-M’s 2010 graduates spent eight weeks in community-based education and 16.5% of them chose to work in community clinics upon graduation.

As Bill likes to point out, these clinics are typically understaffed when it comes to dentistry, “but not one of our sites struggles to have a dentist working there. Our students are gravitating to them.”

“We are seen by our community as part of the solution to inadequate health care,” Pete adds, noting that the community-based education program has also generated new respect for the dental school within the university. “The university understands full well the value we’ve added to the community and sees us playing a key role in positioning the university within the state of Michigan. We’ve done that by providing this care.”

On the western side of Lake Michigan, another dental school has also made remarkable strides in the area of community-based education. The University of Illinois at Chicago (UIC) College of Dentistry had no community-based education requirement prior to 2005, but with the help of a five-year grant from “Pipeline, Profession & Practice: Community-Based Dental Education” (Dental Pipeline Program), a $30 million initiative of the Robert Wood Johnson Foundation (RWJF), the dental school built one of North America’s most successful community-based education curricula from the ground up. In fact, the UIC College of Dentistry was honored with a 2012 William J. Gies Award for Vision, Innovation, and Achievement this past March in recognition of its extraordinary achievements in this and related areas.

As you may know, the Dental Pipeline Program was a two-pronged effort aimed at diversifying the dental workforce and at engaging all dental students in community-based service-learning practice with the long-term goal of improving access to dental care for underserved populations. UIC, which also received funding from RWJF to diversify its faculty, used all of these resources to pursue one purpose, according to Dr. Darryl D. Pendleton, Associate Dean for Student and Diversity Affairs and Director of the Urban Health Program. “It was the vision of the college to get the students into the community,” he told me, “and all of these initiatives supported that vision.”

Dr. Caswell (Cas) Evans, UIC College of Dentistry’s Associate Dean for Prevention and Public Health Sciences, arrived at the dental school in 2004 and soon found himself tasked with implementing the school’s community-based education initiative. In the fall of 2008, he piloted a program with 12 students that is now the norm for all UIC students. Fourth-year dental students (D4s) spend a full 50% of their time in the community, alternating weeks away with weeks in the campus clinic. In order to offer so many external rotations, UIC accelerated its third-year clinical curriculum to provide what Cas calls a “platform for providing dental care under the supervision of community-based preceptors.” The school also introduced curricular elements—beginning in year one—that provide stepping stones to the D4 experience.

The immersion of UIC students in community-based education is leading many of them, like their U-M counterparts, to choose safety-net or community-based practice. For Cas, seeing students make this choice is one of the most rewarding aspects of overseeing the D4 course in community-based education.

“About 10% of the class has an “aha” moment and changes career trajectory as a result of the course,” he estimates.

Both Cas Evans and Peter Polverini also pointed out that working in the community makes students far more productive. UIC found that senior students return from their rotations capable of addressing more complex situations and patient care needs. This experience helped offset clinic revenue lost when students were not available to treat patients on campus. And while UIC concurrently diversified its admissions committee, implemented whole-file review, and partnered to create several preparatory programs for dental school candidates, it appears that the school’s intensive community-based education offerings may also be impacting the types of students who are applying and gaining admission to UIC.

“It’s clear from our website and promotional materials that the college has made a very strong commitment to access-to-care and health disparities and community-based service learning,” Cas explains. “Anyone who applies here understands this intent and emphasis in the curriculum. To the extent that there was any prior hesitancy, students asking, ‘why do we need to do this,’ those types of expressions are no longer heard. Now students are eager to engage in the full extent and benefit of their D4 year.”

The Dental Pipeline Program has touched 23 ADEA member institutions so far, and this year it will enter a new phase. Eleven dental schools have been selected to participate in the Dental Pipeline National Learning Institute (NLI). In addition to receiving small grants to develop year-long projects focused on community-based education or the recruitment of underrepresented minority dental students, awardees will benefit from technical assistance and a number of educational opportunities.

I realize that at some schools the challenges of implementing community-based education appear daunting. Yet the experience of our colleagues in Ann Arbor and Chicago strongly suggests that there is a workable model out there for every school and every partner seeking collaboration. It’s exciting to see that community-based education appears to be delivering on its original promise of attracting dental students to community practice and giving them the skills to succeed in that environment. When you consider the other rewards the U-M and UIC dental schools are reaping—more productive and engaged students, the respect of their universities, and the community’s gratitude—community-based education looks like a sound investment for all of our schools.

If those reasons are not enough to ramp up community-based education, Peter Polverini offers another rationale. He believes that delivering more care in the community will become an economic necessity for dental schools in the near future.

“If dental education is to continue to thrive,” he told me, “I think we’re going to have to shift the types of patients we treat in our building so that we focus on specialty and complex care.”

That’s a topic for another day, but an idea well worth contemplating. Meanwhile, you should know that NLI will offer one more opportunity for grantees to be part of a dynamic cohort of schools that want to invest in addressing access-to-care and workforce disparities. If your institution is not already taking part, please consider applying in 2013.

Charting Progress now includes a feedback mechanism. I encourage you to post your comments about community based education or share information about your program in the space below.