In this month’s letter, Dr. Rick Valachovic talks with North Carolinians to find out how a new model of dental education is bringing dental care to rural parts of the state.
What happens when you recruit students who are committed to rural practice and prepare them to be dentists in rural practice environments? Can such an investment make a measurable difference in improving access to dental care?
East Carolina University (ECU) set out to answer these questions when it opened the doors of its School of Dental Medicine (SoDM) in 2011. The plan for the school had many unique features, which I’ve described in this column before, but what most set this groundbreaking venture apart was the decision to move a substantial portion of clinical education to the community by building eight, identical 16-chair Community Service Learning Centers (CSLCs) in underserved areas across the state. Senior dental students—all of whom hail from North Carolina—spend three nine-week rotations at the CSLCs, practicing dentistry alongside ECU SoDM faculty and residents.
The first entity to partner with ECU to bring dental education to a rural corner of the state was a Federally Qualified Health Center (FQHC) in Ahoskie, a town of nearly 5,500 in eastern North Carolina. Health Center Chief Executive Officer Kim Schwartz, M.A., remembers well her first meeting with Greg Chadwick, D.D.S., M.S., ECU SoDM’s Dean. The conversation that ensued was scheduled for 45 minutes. It lasted almost three hours, and after three years of planning, development and construction, the Roanoke Chowan Community Health Center in Ahoskie became the first FQHC in the nation with a co-located dental school clinic and residency program.
Dentistry’s arrival in Ahoskie worked out well, not least for Nicole Beasley, D.M.D. She grew up in Jackson, about 30 miles away, and recalls having to drive an hour to get to a dentist when she was young. She saw a career opportunity in her community’s lack of dental care and chose to attend ECU SoDM for two reasons: She felt at ease there, and she knew its mission dovetailed with her own aspirations.
After graduation, Nicole completed an Advanced Education in General Dentistry residency at the Ahoskie CSLC, and today she practices at an FQHC in Jackson. “I had always thought I wanted to be back home, but after graduating, I was weighing my options,” she told me. “When it came down to it, I just knew that the whole reason I went to dental school was to be here in the first place. Here’s where I can do the most good.”
Maggie Wilson, D.D.S., M.B.A., Vice Dean and Associate Dean for Student Affairs at ECU SoDM, couldn’t agree more with Nicole’s assessment. “It’s only once our graduates are out there in a practice, in a rural community or an underserved area, that our mission is realized,” she told me.
Maggie and Greg put me in touch with Nicole and another graduate who exemplifies ECU SoDM’s promise. Gustavo (Gus) Gasca, D.M.D., had difficulty accessing dental care as a child because he moved from Florida to North Carolina to Michigan and back each year as his Mexican-born parents followed the harvest. Gus told me he and his siblings needed to have primary teeth extracted, and their permanent teeth came in misaligned. In his brother’s case, the problem was extreme enough to draw unwanted attention from his middle and high school classmates.
As it happened, the family’s desire to see Gus go to college led to a marked improvement in their oral health. So Gus could take advanced placement courses, the family decided to live in North Carolina year-round, a choice that made the family eligible for Medicaid. Gus’s mother was finally able to address her dental pain, and his brother got the orthodontic treatment he needed.
“Getting braces changed my brother’s self-esteem,” Gus told me, and watching that transformation eventually led Gus to pursue a career in dentistry. Today he is practicing at Pollock Advanced Dental Group in Burgaw, where he primarily treats Medicaid patients and is the only dentist in a 20-mile radius who speaks Spanish. He is delighted to be “giving back.”
Where are ECU SoDM’s other graduates?
- The majority—83 of 148—are practicing in North Carolina.
- Seven are practicing out of state, and two will likely return when their spouses complete residencies.
- Another 38 graduates are in General Practice Residencies.
- Fifteen are pursuing advanced dental specialties.
- Two are in the military.
- One is a faculty member at ECU SoDM.
Perhaps the better question is: Are these graduates engaged in work aligned with ECU SoDM’s mission of placing dentists in rural, underserved communities? Apparently many are.
“We’d like to track this by county,” Greg told me, “but even in doing that … you have to peel the onion back. One of our graduates is working in Mecklenburg County. That’s urban, but he’s working in two Medicaid practices and seeing 100% Medicaid patients, so his work is clearly mission aligned.”
Back in Ahoskie, Kim sees ECU SoDM’s mission in practice every day. The Ahoskie CSLC provides continuous care for an established panel of patients and prioritizes care for individuals who arrive at the FQHC with dental needs. An arrangement with the Roanoke-Chowan Foundation allows the center to provide complex procedures on a sliding fee scale for uninsured patients.
Kim calls the impact of this care “miraculous.” One patient saw her diabetes improve after receiving dentures that allowed her to get off a soft diet of applesauce and sweet potatoes. Another patient found a job after his missing front teeth were replaced. A third was able to sleep again after being treated for the condition causing her dental pain, Kim told me. “To literally have this clinic right here in Ahoskie, this little rural town in eastern North Carolina, and to be known for it. … People are very proud of that fact and proud of the association with ECU,” she says. “They finally have an option for oral health and (this is not too strong a word) hope that there’s someone looking out for their oral health needs.”
There’s no question in Kim’s mind that by providing one-stop shopping for medical and dental care at Ahoskie, ECU SoDM has improved the lives of some of the health center’s most vulnerable patients. The school’s statewide numbers are also impressive. Since that first CSLC opened in 2012, Greg told me, ECU SoDM students, residents and faculty have treated 49,720 patients at the Greenville campus clinic and the eight CSLCs distributed throughout the state. More than 15,000 of those patients were enrolled in Medicaid.
These numbers are welcome news in a state with one of the lowest dentist-to-population ratios, roughly five per 10,000. According to the Health Resources and Services Administration, North Carolina has roughly 140 Health Professional Short Areas when it comes to dental health. So why are so few dentists practicing in rural parts of the state?
When I asked Nicole if she had thought about opening her own practice in the area, she expressed doubts about her ability to make that happen. She says it’s difficult to find front-desk staff, dental assistants or a business manager. Additionally, because so few people have private insurance, it can be challenging to develop an adequate patient base. Instead, she has set her sights on one day being the Ahoskie CSLC clinic director—a goal with which no one at her alma mater will argue.
Despite the obstacles, rural practice can be financially viable. “A lot of people look at the Medicaid fee scale and say, no way can I take part in that,” Maggie observes, but that reaction is too hasty, she tells students. “You can serve Medicaid patients and still earn enough to pay off your loans, send your kids to college, buy a home, etc., but you need a well-designed vision and a practice plan.”
To equip students with the tools they need to care for underserved patients in a sustainable way, the ECU SoDM curriculum explores public policy, financial barriers to care and the sociology of poverty. The school has also hired Hillary Harrell, who serves as Student Financial Support Manager. She works with students to help them figure out how they will pay for dental school, teaches in the practice management curriculum, and assists students, residents and graduates with identifying practice opportunities that are aligned with ECU’s mission. Her support ranges from critiquing business plans to helping students arrange for loan repayment to coaching students on salary negotiation. With a number of first-generation college students among ECU SoDM’s graduates, many without a family member to guide them, Maggie says, Ms. Harrell can be a lifeline.
So, what’s next for Ahoskie? According to Kim, the CSLC could use several more dentists just to meet the routine needs of the patients at the FQHC. That may happen one day, but Greg plans to proceed cautiously.
“We have room for expansion within the facilities, but we’re trying to make the center sustainable—not just economically but also educationally. We’re not just a safety net clinic. Students need to do crowns, bridges, root canals, partials and not just provide basic care.” Greg echoes Nicole’s concerns when he adds, “In rural areas, it’s hard to recruit a mix of patients who can afford more complex treatments, and Medicaid doesn’t cover much.”
It has been clear for years that Greg and his colleagues are contributing to the transformation of dental education. Six years into ECU’s experiment, it seems irrefutable that the CSLCs are achieving their early goals and having wider impacts. By bringing dental care to rural populations, ECU SoDM students, residents, faculty and graduates are not only making a measurable dent in their state’s access-to-care challenges, they are also helping to reinvigorate communities. When CSLC practitioners eliminate pain and restore smiles, they participate in a process that can lead to employment and improved economic circumstances. Kim also reports that the presence of young dentists drawn from the community is inspiring a new generation to consider pursuing dental careers.
These are some of the good things that happen when you recruit students who are committed to rural practice and prepare them to be dentists in rural practice environments. I look forward to hearing more good news as the program grows.