In this month’s letter, ADEA President and CEO Dr. Rick Valachovic talks with dental educators at three schools that excel at meeting dentistry’s social mission.
It seems as though hardly a day goes by that I don’t read an article or an online discussion with some mention of the social determinants of health.
In the last several years, a growing consensus has emerged that the best way to get a handle on health care costs and improve population health is through interventions that address these social determinants—defined by Healthy People 2020 as the conditions in the places where people live, learn, work and play. Research increasingly supports the idea that these conditions can be just as influential as biomedical factors, such as a person’s birth weight or genes, when it comes to determining health status. The good news is that, unlike our fundamental biological makeup, our social circumstances are amenable to change and can be influenced by public policy.
From a dental perspective, viewing our nations’ health challenges through a public health lens-taking steps to change the conditions that are linked to disease rather than just striving for better treatments—makes perfect sense. Nearly all dental diseases and conditions are preventable, and while we can—and do—promote prevention at the individual level, we know from experience that community-level prevention is even more powerful. Our decades-long history with community water fluoridation—one of the 10 great public health achievements of the 20th century—aptly illustrates that point.
As self-evident as all this may seem to many of us, I wonder whether we are fully conveying the importance of public health and public policy in our classrooms and clinics? Like most of today’s students, I entered dental school with every intention of becoming a private-practice dentist in my hometown, but my residency in pediatric dentistry at Boston Children’s Hospital opened my eyes to other professional pathways. At that time, the city lacked community water fluoridation, and I witnessed high levels of childhood caries as a result. I came to appreciate the impact of community factors on the health of the patients I treated and decided to enter the dental public health residency program at Harvard. That experience filled me with a strong desire to pursue a dental career that would allow me to impact populations rather than treat one patient at a time.
Not every dental student will follow in my footsteps, nor should they. Hometowns still need dentists after all. But to make major headway in improving oral health across North America, we need to make sure all our students appreciate that they are responsible to their communities as well to their individual patients.
A.T. Still University’s Arizona School of Dentistry & Oral Health (ASDOH) was founded on that proposition. Its mission is to help address our nation’s gap in access to dental care by educating “community-responsive general dentists” who are committed to providing access to care for underserved populations. Several things set ASDOH apart:
- Students engage in service learning each year and spend at least half of their fourth year living and working in the community.
- Public health certification is woven into the predoctoral program so that all students come to view dentistry through a public health lens.
- Roughly 25% of dental students build on their public health certification and opt to earn a Master of Public Health degree as well.
It’s also worth mentioning that ASDOH leads in graduating American Indian dentists, the vast majority of whom return to their communities to practice.
“Social mission is built into ASDOH’s culture and curriculum,” says Dean Robert (Bob) Trombly, D.D.S., J.D., and the school’s graduates reflect this. Almost a quarter of them work in Federally Qualified Health Centers, the Indian Health Service and the military, and those who pursue private practice report a high level of involvement in community service and providing pro-bono care for underserved patients.
Bob believes that ASDOH’s strong emphasis on public health does as much to draw in students whose values align with ASDOH’s social mission as it does to instill a public health perspective.
“A.T. Still University, the National Association for Community Health Centers and our founding Dean Jack Dillenberg envisioned the dental school’s creation as a strategy to improve access to care. Community health centers continue to work with us each year to identify and recruit students,” Bob notes, which is why some individuals enter the dental school having already earned an M.P.H. degree.
ASDOH is not alone in offering a public health certificate or the opportunity to earn a dual degree—an option at roughly half of our schools. Nevertheless, public health is not necessarily integral to the teaching of dentistry.
“In dental school, usually we say, if you’re interested in public health, it’s over here,” says Caswell Evans, D.D.S., M.P.H., Associate Dean for Prevention and Public Health Sciences at the University of Illinois at Chicago College of Dentistry (UIC COD). He would like to see public health’s often-peripheral status change, and he’s looking for opportunities to make dentistry’s social mission more visible in a consistent and organized way.
Like ASDOH, UIC COD places a high value on educating students in the community, where they can be exposed to the people most in need of dental services. UIC COD’s commitment to public health and community engagement is visible through 16 weeklong extramural rotations in mission-driven community-based clinics. Classes on access to care, health inequities, social justice and the ways in which delivery systems strive to address these issues are also part of the mix.
Another exemplar in this regard is the East Carolina University School of Dental Medicine (ECU SoDM), which I wrote about in January. The school’s unique model of distributing clinical education across ECU SoDM clinics in underserved regions of the state gives students an acute awareness of their patients’ circumstances. As the Dean, D. Gregory (Greg) Chadwick, D.D.S., M.S., put it when we spoke, placing students in the community to care for patients is “more than just filling and drilling and extracting. It’s appreciating how people live.”
Greg is pleased with his school’s record of placing graduates in safety-net settings, but in his view, the availability of more dental providers will not be sufficient on its own to solve North Carolina’s oral health problems. Achieving that goal will require a public health perspective. “You’re going to improve oral health with community involvement, through prevention, by having your graduates understand that they have to be leaders in the community,” he insists.
Helping students develop that public health perspective appears to be closely tied with the time they spend immersed in the community. Although the Commission on Dental Accreditation’s Accreditation Standards for Dental Education Programs require that schools make community-based experiences available, these experiences are not mandatory, and their extent varies considerably from institution to institution. Nevertheless, we’ve come a long way from the days when all clinical education occurred within the footprint of the dental school. Today, a considerable portion of clinical education happens in the community, making it easier for students to grasp the public health nature of their work.
Indeed, each year the ADEA Survey of Dental School Seniors reveals the increasing value that students place on their community-based experiences and the increased likelihood that they will expand the pool of patients they treat as a result. These developments are welcome and worth building on, but so are many other facets of what we do. As Bob put it, “Each school has its own unique mission and focus. You have to work with what’s consistent with the overall university mission.”
I agree. Even at ECU SoDM, where Greg calls social mission “part of our DNA,” other priorities also demand attention.
“We are having more and more conversations about whether it is enough to educate people who are technically skilled and kind and competent,” Margaret (Maggie) Wilson, D.D.S., M.B.A., ECU SoDM’s Vice Dean and Associate Dean for Student Affairs, told me. “I’m hearing from some colleagues that it may not be enough, but it gets down to resources—not just money but also your energy, your time.”
Inevitably, all dental schools must first focus on helping students gain the skills they need to provide care for individual patients. Beyond that, institutional missions will vary based on their history and tradition. For some, the emphasis will be on research and the creation of new knowledge, treatments and technologies. For others, advancing the quality of teaching and learning will take center stage.
Whatever these distinctions, our institutions must also attend to their social missions, consider how they can improve the health of the communities they serve and prepare their graduates to contribute to the public good. These goals are a natural fit for a profession rooted in prevention. Viewing what we do through a public health lens will help us achieve these aims.