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Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explores how one dental school and one state are framing a response to the opioid epidemic that keeps dental pain mitigation in sight.

Dental pain is real, and most of us were taught that the most effective way to alleviate severe pain was with opioid painkillers. As a result, most dentists prescribe them—with benefits but also unintended consequences for our patients. Today, the majority of young people aged 12–18 who become addicted to painkillers were first prescribed them by a dentist. Given that each year 3.5 million people, most of them young, have their third molars extracted, our role as significant opioid prescribers should come as no surprise. But the bottom line is this: Despite our best intentions, dentists have contributed to what has now become an epidemic, and we need to take an active part in resolving it.
Many of us in academic dentistry are doing just that. ADEA co-hosted a summit on the opioid epidemic with the Substance Abuse and Mental Health Services Administration (SAMHSA) in August. The meeting convened representatives of 17 southern and mid-Atlantic dental schools to learn about the scope of the problem and share strategies that academic dental institutions can use to prevent prescription drug misuse and addiction. These strategies include:

  • Screening patients to identify their risk for substance misuse.
  • Educating faculty and students about pain management, addiction and prescribing practices
  • Consulting prescription monitoring programs (PMPs) to identify patients who may be “doctor shopping.”
  • Developing relationships with addiction treatment providers to facilitate referrals.

Most of the dental schools present at the summit had already taken concrete steps in these directions, and the three Boston-based dental schools—Boston University Henry M. Goldman School of Dental Medicine (GSDM), Harvard School of Dental Medicine (HSDM) and Tufts University School of Dental Medicine (TUSDM)—had gone even further, engaging in a state-sponsored effort to create dental education core competencies for the prevention and management of prescription drug misuse.
(To learn what’s happening in other states, see the 2017 ADEA Summary of State Legislation and Regulations Addressing Prescription Drug and Opioid Abuse on the ADEA Advocacy and Government Relations key state issues webpage.)

Ronald Kulich, Ph.D., of the Craniofacial Pain and Headache Center at TUSDM, co-chaired the competency-creation effort and spoke at the summit. He explained that in 2015, Massachusetts Governor Charlie Baker asked the state’s medical schools to develop a set of core competencies that would address the opioid epidemic. When these were complete, the dean of the Tufts medical school approached the TUSDM dean, Huw Thomas, B.D.S., M.S., Ph.D., and asked him to sign off on their use by dental schools. Huw asked Ron to weigh in.

“Their fit for dentistry was, at best, not perfect,” Ron told me. “Dentists deal with acute pain. We wanted to make sure that pain was in the forefront.”

TUSDM volunteered to form a new working group, which Ron co-chaired with Huw and David Keith, D.M.D., B.D.S., Professor of Oral and Maxillofacial Surgery at HSDM. The Governor’s Dental Education Working Group on Prescription Drug Misuse developed an independent set of dental core competencies, which have now been adopted by the three Massachusetts dental schools and can serve as a guide to dental educators elsewhere in the country.

This policy initiative was one of several in the state, which has been hard-hit by the opioid epidemic. Massachusetts has also established a PMP that collects dispensing information on controlled substances to help prescribers deter drug diversion—the practice of making prescription drugs available to another person for illicit use—and assess whether their patients might be at risk for drug abuse.

I wanted to discuss these activities further with Ron and find out what steps TUSDM is currently taking to prepare graduates to prescribe appropriately. Ron arranged for me to speak with two of his TUSDM colleagues as well: William Jackson, Psy.D., Assistant Professor and Co-Director of the Interprofessional Facial Pain and Headache Rounds, and Ellen Patterson, M.A., M.D., Assistant Professor and Director of Interprofessional Education. Ellen is taking the lead on translating the core competencies into the predoctoral curriculum.

Content related to prescribing and addiction has already been woven into the first and second years:

  • Starting with Introduction to the Dental Patient courses in years 1 and 2, students learn to identify risk factors for addiction and to use screening tools. (Tufts uses the NIDA Quick Screen developed by the National Institute on Drug Abuse. A SAMHSA-developed tool, SBIRT, which covers screening, brief intervention and referral to treatment, is also available and has been integrated in the curriculum at GSDM.)
  • Students and faculty also are invited to take part in weekly Interprofessional Facial Pain and Headache Rounds, during which faculty and regional experts present on pain and addiction. (Other health professionals are welcome to attend. Contact Ron if you’re interested.)
  • Tufts hosts a yearly educational program where students hear from law enforcement about the diversion of prescription drugs for nonprescription uses. Students “rub shoulders” with police and learn that they are “not the bad guys,” Ron says, and the officers in attendance gain a better understanding of the complex decision-making challenges prescribers face.

Tufts also prepares students to routinely use the Massachusetts PMP in their practice. “Dental students are not familiar with the vast array of medications catalogued in the PMP,” Ellen told me, “and the electronic health records used by most dental schools are not typically set up to flag medications that carry risks of addiction.”
Ron agrees that dental records are not well designed for that type of intervention, and they reveal other challenges as well. “We mined about six years of dental records looking at opioid use and other things,” he told me. “Ibuprofen was spelled 12 different ways, and that’s just the ‘tip of the iceberg.’ So we have work do to in terms of how prescription drug monitoring is adopted by the field in general.”

The next step will be to build prescribing education into the clinical portion of the curriculum so students understand that discussing a patient’s risk for addiction is part of their job.

“Risk assessment for substance use is about more than identifying which medications patients have been prescribed,” William told me. “It’s also about assessing behavior. How are patients using those medications? Are they engaged in risky behaviors?”

“This broader risk assessment is not yet standard practice in dentistry,” Ellen added. “To achieve that will require a culture shift.”

The Tufts team is creating video vignettes to help students and faculty become more comfortable with discussing medication use with patients. “These are not difficult or lengthy conversations. They are just awkward conversations,” Ellen said, “but once you’ve done it a few times, it becomes second nature.”

Ellen is a physician and rightly observes that during their training, medical students watch both residents and attending physicians conducting patient assessments over and over again. Dental students rarely get that experience. She hopes the videos will provide a similar type of exposure so that dental students become comfortable with the process.

Ellen plans to eventually train a cadre of standardized patients with whom students can practice these interactions. Simulating patient assessments will help students appreciate the human complexity of treating dental pain in a way that mitigates risk for their patients. As William pointed out, “Pain is not just a physical sensation. There are a lot of psychological aspects to the pain experience.”

Ron and Ellen agreed. “When we’re asked to assess pain,” Ellen observed, “we immediately think about the intensity of the pain on a scale. But really, what we need to be measuring is function. The patient’s ability to function is a much better measure of whether or not their treatment is successful.”

Functional assessment represents a significant departure from the “fifth vital sign” view of pain that was introduced by the American Pain Society in 1996 and disseminated by The Joint Commission, which accredits hospitals. Sadly, as Ron points out, this back and forth in our relationship with pain is nothing new.

“Back in the 1800s, we were going through the same process in terms of concern about opioid use and conflict of interest with physicians who were prescribing various pain treatments. Fears associated with opioids, overprescribing and concerns over non–evidence-based medicine has been happening in cycles for the last 200 years.”

Fortunately, there are also periods of progress, but these require the type of broad-based approach that Massachusetts is championing and that Tufts and some others are putting into practice.

William wants dental schools to understand that revising curricula is not sufficient on its own. Policy work at the state level is vital to solving the problem, and so is institutional assessment. “We need to ask, How are opioids being prescribed, and what type of pain medications are being used within the dental school?”

Tufts is monitoring its own prescribing practices and has found that faculty now write 20 prescriptions per 1,000 visits as compared to 30 prescriptions five or six years ago. Perhaps most notably, the endodontic department, which adopted a policy of prescribing over-the-counter medications first, now has an exceptionally low opioid prescribing rate.

The school has also begun collecting data on use of the state’s PMP through the efforts of a third-year dental student, Jessaca York, and her supervisor, Bhavik Desai, D.M.D., Ph.D. “They found that there were 15,000 visits over three years with almost no documentation of PMP results,” Ron told me. Now that Tufts has this baseline data, Ron and his colleagues will watch to see how things change. They’ll also be assessing their students in about 18 months to see whether they have acquired the desired pain-management and risk-prevention skills.

So, the call to action is clear: We must act on multiple levels to reduce patients’ risk for addiction. We need government policies and resources that support better prescribing, institutional accountability for prescribing practices and curricula that prepare the next generation to take a holistic approach to treating pain.

Tufts may be unique in its three-pronged approach to addressing the opioid crisis, but it is not alone. Harvard’s and Boston University’s dental schools are also trailblazers, and many other ADEA member institutions include individuals who are taking courageous steps to change prescribing practices within their establishments.

Allied dental programs also have a vital role to play in this effort. Ron, Ellen and William pointed out that patients may spend most of their dental visit talking with dental hygienists or other allied personnel.

“Dental hygienists have a very preventive focus,” Ellen said. “We think they’re an underutilized resource in addressing this issue. Even though they don’t typically prescribe opioids, they are very much part of the solution.”

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic considers how the movements toward health care integration and paying for value might affect dentistry.

Those who attended the 2017 ADEA Annual Session & Exhibition in March likely heard the buzz generated by a Chair of the Board Symposium on health care transformation. The speaker, Nirav Shah, M.D., M.P.H., Senior Vice President and Chief Operating Officer for Clinical Operations at Kaiser Permanente in Southern California, posed several provocative and urgent questions:

  • How can we minimize the variation in the delivery of dental care?
  • How can we provide patient-centered rather than dentist-centered care?
  • How will we prepare to shift from a procedure-based to an outcome-based profession?
  • What areas of dental care are ripe for bundled and other forms of value-based payment?
  • How will we help thousands of solo practitioners adapt to greater delivery system integration?
  • How might dental hygienists and dental therapists help solve the need for unmet care?

The primary goal, said Dr. Shah, is to evolve an ecosystem of health care providers working for the greater good; in his view, the key to reaching that goal is standardization. He used the automotive industry to illustrate his point. From Henry Ford’s introduction of the assembly line to Toyota’s development of lean manufacturing, automobile makers have transformed their industry and produced products that are affordable, reliable and widely accessible—three fundamental goals of health care delivery that today remain elusive.

“In complicated systems, standardization is innovation,” Dr. Shah says. He and his colleagues have applied this principle at Kaiser Permanente with some truly remarkable results.

Take, for example, the way Kaiser Permanente handles hip-replacement surgery. For more than half of its patients, hip replacement has become an outpatient procedure. How? To begin with, the patient goes into the surgery fully informed about and prepared for the recovery process. A nurse has already visited the patient’s home to make sure there is a bed on the ground floor and that handrails are installed in the bathroom. Walkers and canes have been delivered, and a pharmacist has visited to explain how the patient’s medication will change. Family members who will be providing care in the home are educated about their roles as well.

On the provider side, evidence-based care rules the day. Anesthesiologists are taught to use an anterior block, which allows the patient to walk off the operating table without pain, and every patient receives that block. Orthopedic surgeons are told which devices to use, and everyone on the team is thoroughly acquainted with the ins and outs of how these work. Patients are sent home the same day, minimizing the risk of hospital-acquired infections, and a physical therapist comes to the home the next morning. The result? According to Dr. Shah, Kaiser Permanente achieves “better care, higher quality, lower costs and better safety.”

The advent of bundled payments that reimburse providers for all of the services associated with an episode of care has been key to incentivizing these types of innovations. The Centers for Medicare & Medicaid Services reimburses Kaiser Permanente and other providers a fixed amount per joint replacement, unless, of course, something goes wrong.

Under the current fee-for-service reimbursement model, hospitals take in more revenue when patients develop infections during their stays or are readmitted to the hospital following discharge. Under the bundled-payment model, providers are docked a percentage of their reimbursement when these adverse events occur, so investing up front in better patient care is financially wise as well as good practice.

The success of the hip-replacement bundle and other value-based payment experiments suggests that we’ll be seeing a continued shift away from fee-for-service medicine toward greater care integration. How this shift will impact dentistry is less clear, but no one doubts that we will also be swept up in the coming change. During his talk, Dr. Shah asked where bundled payments might work well for dental care, and ADEA members had lots of ideas—dental hygiene care for diabetes patients, dental implants for full mouth rehabilitation, and orthodontic care, among other services.

Dr. Shah described similarly impressive protocols Kaiser Permanente has put in place for averting diabetes-related blindness and for easing kidney-failure patients into a home dialysis regimen that allows them far greater control over their symptoms. He told us that in each case, treatments have become less expensive, safer and more patient-centered, and the quality of patient health has improved in tandem.

These achievements rest on several strategies:

  • Moving care out of the hospital or clinic and into the home.
  • Reducing the amount of care in the hands of specialists and empowering the whole team.
  • Requiring that providers follow evidence-based protocols.
  • Practicing transparency to improve quality.

How might we in dentistry adopt, and perhaps adapt, some of these practices to serve our own goals of increasing access, lowering costs, and improving care quality and the patient experience?

In Dr. Shah’s view, we need to begin by reducing our traditional isolation. He is firmly convinced that quality care emanates from teams, not from individuals. When it comes to one- and two-person primary care practices, Dr. Shah insists that the data show these practices provide substandard care. What does that mean for the legions of dentists in private practice? Dr. Shah challenged us to create an “off-ramp” to lead existing solo dental care providers into large integrated systems of medical and dental care that can “deliver reliably on quality.” Kaiser Permanente has already blazed a path, integrating dental- and medical-care delivery in its Oregon facilities. Dr. Shah called the arrangement a “spectacular success,” and said the company plans to replicate the model in other regions where it provides care.

Dr. Shah also had some concrete proposals for adapting our educational model to better prepare students for the integrated, person-centered care environments of the future. Among his suggestions:

  • Spend less time teaching students about surgery and more time teaching them about prevention.
  • Educate them to work in teams.
  • Foster their creativity, perhaps by having them work on some of the “wicked” problems that continue to burden health care.
  • Help them develop leadership and performance-improvement skills.
  • Acquaint them with systems engineering and encourage them to co-design care models and workflows in collaboration with their patients.

Medical education is adopting these approaches, Dr. Shah told us, but he also expressed frustration at the slow pace of change. It currently takes about three years, he said, for new hires to unlearn the habits (such as ordering too many tests) that Kaiser Permanente wants physicians to break. To address this concern, Kaiser Permanente is creating its own medical school in Pasadena, CA, to prepare physicians who are ready to deliver “Permanente medicine” upon graduation. The curriculum will emphasize leadership skills, quality improvement and systems engineering, positioning graduates to lead change wherever they go.

Kaiser Permanente’s foray into medical education represents a “deliberate decision to start over” rather than reform an educational system that has been focused on the basic sciences and research since the release of the Flexner Report on medical education in 1910. Kaiser Permanente’s departure from the educational status quo—like many of the other ideas Dr. Shah espoused—will be controversial. In dental education, for instance, we have striven to embrace innovation while still retaining and expanding our research enterprise. Likewise, not all dentists would be comfortable with the flattened hierarchy that characterizes Kaiser Permanente teams, and many of us would question the use of evidence-based protocols that obviate provider decision-making or undervalue the provider’s clinical experience in determining the best course of care.

Nevertheless, Dr. Shah’s provocative ideas demand the consideration of anyone with a stake in shaping the future of dental care delivery. If we choose to embrace integrated delivery models, expanded care teams and increased standardization, what might we gain?

Dr. Shah argues that standardizing care delivery will ultimately free health care providers from the time-consuming activities that currently prevent them from getting to know their patients, engaging with them in care planning and customizing care to better meet their individual needs. If Dr. Shah’s experience is any guide, he and others at Kaiser Permanente are onto something big, and our community would do well to consider the thought-provoking questions he posed. Coming to a consensus on the answers won’t be easy, but we must try—for the sake of our professions and our patients’ health.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic describes an ADEA initiative that supports adjunct allied faculty and may serve as a model for future online educational offerings.

What if future academic allied leaders were already in our midst, just waiting for an easily accessible opportunity to develop their skills and move to the next level? That was the premise behind a pilot leadership program developed by ADEA last year in collaboration with the American Dental Hygienists’ Association (ADHA).

ADEA/ADHA Leadership Essentials for Adjunct Faculty (ADEA/ADHA LEAF)—fine-tuned in 2017 and now called ADEA LEAF—is an interactive, self-paced online course specifically for part-time allied dental faculty members. Using Canvas, a learning management system made available by Eastern Washington University (EWU), the course guides participants as they assess their strengths, secure mentors, set goals and develop conflict management skills and a personal leadership philosophy.

Rebecca Stolberg, RDH, M.S.D.H., Professor in the College of Health Science and Public Health at EWU, is the course director and served on the ADEA/ADHA Work Group that created the program. Why the focus on adjuncts?

“When you look across allied dental programs, we all have way more part-time or adjunct faculty than full-time faculty,” Rebecca points out. “Program directors support their full-time faculty with development dollars—if they can—but adjunct faculty don’t get much in terms of professional development.”

Leadership development for adjuncts is not just about filling that opportunity gap. It’s also about developing a cadre of educators and program directors who can fill anticipated vacancies as full-time faculty members retire. Rebecca has been in dental hygiene for almost 30 years, and she is concerned. “We hire our alumni the day they graduate because we don’t have educators out there to hire,” she says with dismay, noting that many flounder without the leadership development skills that ADEA LEAF is trying to impart.

A dearth of seasoned professionals who can take on teaching and leadership roles also affects dental professional associations, state boards and other entities that rely on experienced, capable individuals to shape policy and keep our professions strong.

In its first year, ADEA LEAF impacted several of these areas. Of the 17 dental hygienists in the initial cohort, three are now full-time educators, four have entered graduate programs, two have been appointed to advisory positions by their institutions, and four have increased their teaching loads. These excellent outcomes are a testament to the can-do spirit of the program.

For Annette Stelter, RDH, an adjunct faculty member in the Department of Dental Hygiene at West Coast University, participating in ADEA/ADHA LEAF in 2016 was “absolutely profound.”

“Here I thought I was going into retirement, and now at 50, I’m going back to school to get my master’s degree to have another career,” she says. She attended the program on the recommendation of her dean, who knew of Annette’s interest in ultimately obtaining a full-time faculty position.

To achieve this goal, she was planning to pursue a master’s degree in dental hygiene, but she says that ADEA LEAF gave her a taste of what organizational leadership was all about and persuaded her to change direction. “Until I took the course, I wasn’t even considering this as an option,” Annette told me. Now she is pursuing a master’s degree in organizational leadership and hopes eventually to become the clinic manager at her school.

Annette also praises the program’s structure and the way it balances independent and interactive learning. Through the course, she made friends across the country, and a year later she is still in touch with them.

ADEA/ADHA LEAF alumna Anne Miller, M.S., an adjunct faculty member at UC Blue Ash College, a regional college within the University of Cincinnati, also appreciated the balance between independent and interactive learning. “We didn’t have a lot of live conversation, but we got to know each other through the discussion boards,” she says. “As the course progressed, people felt safer and safer to share more about their desires and their dreams.”

Anne’s dream is to become a full-time faculty member who can influence new dental hygienists to view themselves as professionals.

“Dental hygiene programs could focus more on leadership skills and talk about what you can bring to your position no matter what title you hold,” she says. For Anne, who also belongs to her state dental hygiene association and serves as president of her local component, the program offered an affirmation of her career plans. She envisions eventually moving into a clinic coordinator position, or perhaps one day, becoming a program director.

This is exactly what the work group was hoping for when it conceived of ADEA/ADHA LEAF—a program that would instill in participants a belief that “I can go on and do this,” as Rebecca put it. Although ADEA has many established leadership programs for full-time faculty, a number of these folks have sent inquiries to Rebecca about LEAF. “People are eager for this type of development,” she told me, “and the more economical, the easier the access, the better.”

Annette agrees, and adds that she would like leadership essentials to be “part of the curriculum in all the dental hygiene programs. It’s important to have these skills even when you’re working in collaboration with patients.”

ADEA is in the early stages of developing an updated portfolio of e-learning opportunities that we hope to make available to all of our members, perhaps as early as 2018. In the meantime, ADEA LEAF puts leadership skills within reach of current adjunct faculty and starts them down a path toward deeper leadership development.

The second iteration of the course starts this month with a few refinements from its original format. The 25-credit course will run for eight weeks with adjunct dental assisting and dental lab technician faculty invited to attend alongside their dental hygiene colleagues. At $14 per continuing education (CE) credit hour, the program is a phenomenal bargain, and—not surprisingly—it quickly sold out.

West Coast University Dean of Dental Hygiene Michelle Hurlbutt, RDH, M.S.D.H., D.H.Sc., plans to send members of her adjunct faculty to the ADEA LEAF program each year. If Annette’s enthusiasm for continued professional development is any gauge, Michelle is making a wise investment in the health of her program and her profession.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares news of a joint effort with the American Dental Association to change how dental professionals are assessed for licensure.

If you’ve ever talked with your colleagues about the clinical exams used for dental and dental hygiene licensure, you’ve heard this familiar litany of complaints: They are costly for students, often unfair to patients and fraught with potential for ethical compromise.

We’ve been hearing these grumblings for decades, but by and large, we’ve resigned ourselves to the idea that the way things are is the way they will remain. I’m happy to report that this grudging acceptance is giving way to new optimism. Change is visible on the horizon. Getting there is just a matter of time.

During the past 10 years, a few pioneering states have experimented with alternative ways to assess clinical competency for initial licensure—mandatory postgraduate training, portfolios, curriculum integrated format (CIF) exams and objective structured clinical exams (OSCEs). Most recently, Colorado opted to accept all of these alternatives as well as all of the traditional state and regional exams as pathways to licensure for both dentists and dental hygienists.

Colorado’s decision may be a bellwether of a nationwide shift away from the status quo and a major step toward license portability.

“It’s been a problem for dentistry for some time that state laws vary so much,” says Karen Hart, Director of the Council on Dental Education and Licensure at the American Dental Association (ADA). “When new and mid-career dentists want to move from one state to another, often they are required to retake the licensure exam, which includes demonstrating their skill on a patient. That’s burdensome, and according to available, albeit limited, published psychometric analyses of current patient-based licensure examinations, patient-based exams do not consistently and reliably determine an individual’s competency.”

ADEA went on record in 2011 opposing the use of live patients in licensure exams, and the ADA has held a similar position since 2005. With the increased migration of dentists across state lines in recent years, licensing reform became a top ADA priority, prompting that organization to invite ADEA to form the ADA/ADEA Joint Licensure Task Force—a recent development that should finally give isolated state-level experiments the fuel they need to scale up to a national level.

The Joint Task Force held its first meeting a year ago in August, and this February released a report with five recommendations:

  • Increase awareness and understanding of emerging licensure models.
  • Promote further development and piloting of alternative licensure models.
  • Increase understanding of the accreditation process.
  • Promote research and distribution of findings from alternative licensure models.
  • Publicly recognize and collaborate with others engaged in alternative licensure models.

ADEA and the ADA haven’t always seen eye-to-eye on every issue, but both organizations have fully endorsed the Joint Task Force recommendations. Even more importantly, both organizations have committed to concrete action to move the Joint Task Force recommendations forward. The ADA has established a steering committee to oversee the development of a Dental Licensure OSCE (DLOSCE), similar to the one currently used to license dentists in Canada and Minnesota. In parallel, ADEA will develop a template for a portfolio licensure exam along the lines of the one developed in California. These activities will advance our goal of creating valid and reliable assessments that states can use to test for clinical competency without involving patients. Over time, these alternatives might expand to include the use of manikins or haptics as the technology and economics of virtual testing evolve.

ADEA Immediate Past Chair of the Board Cecile Feldman, D.M.D., M.B.A., Dean of Rutgers, The State University of New Jersey, School of Dental Medicine, championed the idea of ADEA and the ADA coming together on common ground to improve the way U.S. dentists are licensed for practice. She serves on the Joint Task Force as Co-Chair and is the first to agree with my assessment that change is on the horizon, but she also points out that a long road lies ahead.

“The partnership between the ADA and ADEA was a natural,” she told me as we reflected on what has been achieved so far. “If you think of the licensing process as a three-legged stool, the testing and licensure folks are the other major piece of this. Whether they’re going to make some of the changes we feel strongly about remains to be seen.”

Indeed, at an April meeting of the American Association of Dental Boards, it quickly became clear that the ADA’s proposed DLOSCE remains controversial among the very dental boards that might ultimately be called upon to recognize it.

“The DLOSCE will take two to three years to develop,” Karen estimates, “and then we will have to advocate state-by-state for its adoption. In the meantime, we will work with state dental boards, state dental associations and dental schools on license portability so that all of the clinical licensure exams can be accepted by each state.”

Reaching these goals will require continued patience but also a sense of urgency. Our efforts are occurring at a time of heightened federal interest in occupational licensing. There has been a lot of discussion about just how much certification and licensure is really needed to protect the public, with the Federal Trade Commission devoting considerable energy to address this concern. In July, the agency’s Economic Liberty Task Force held its first public roundtable on the matter.

Given these pressures, I’m heartened by the strong partnership ADEA has formed with the ADA and the rapid progress we’ve made in a single year. As we move forward on achieving universal acceptance of a nonpatient-based licensure exam, we are inviting the American Student Dental Association to join us under the umbrella of a newly established Coalition for Reform in Dental Licensure.

Those of us who have been tackling this problem for decades know that it will take some time to convince everyone that change is not just possible, but in everyone’s best interest, including the public’s. There is a growing recognition that the issues dental boards handle on a routine basis have little to do with the dentists entering the profession and a lot to do with the behavior of dentists already in practice. Whether fraud, substance abuse, inappropriate prescribing or failure to meet standards of care, misconduct can arise at any point in a decades-long career. If licensure becomes more standardized, could more board resources be spent on curbing these behaviors? Maybe.

ADEA is planning to review the complaints that dental boards address to identify specifically which disciplinary actions occur most frequently in all 50 states and the District of Columbia. This research may reveal whether new dentists who gain licensure through alternative means are any more likely to be censured than their peers in states that use patient-based exams. If the answer is no, it will become harder to justify using patient-based exams or not letting licensed dentists and dental hygienists practice across state lines.

As Cecile has said, “The boards’ perception that these clinical exams are effective in preventing unqualified practitioners from entering practice—the two just aren’t related.” For those who disagree, this coming research should shed additional light on the matter and hasten the day when alternatives to live-patient licensure exams are implemented across the nation.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares news of the movement to build resilience among health professionals.

The statistics are alarming. So many physicians commit suicide that in any given year it could take up to four medical school classes of 100 graduates to replace them. No one tracks the number of physicians in training who end their own lives, but a systematic review and meta-analysis published last December in JAMA, the Journal of the American Medical Association reported that 11% of medical students consider taking this action.

Compared with the general public, physicians are roughly twice as likely to commit suicide, and for decades we’ve assumed that dentists were also at higher risk, even though studies in the 1970s and ‘80s found no evidence to support that assumption. Does that mean our profession doesn’t have a problem? Hardly. It simply means our profession lacks definitive data about what is truly happening with students, residents, fellows and practitioners when it comes to burnout, depression and suicide.

What we have studied is dental student stress—undoubtedly a precursor to these other phenomena. In 2014, researchers at McGill University Faculty of Dentistry conducted a systematic review of the literature on stress in dental students. The researchers found that considerable amounts of stress emanate from the demanding nature of dental education, specifically examinations, grades and workload. Interestingly, dental students reported higher levels of stress than their medical school counterparts—reason enough for ADEA to give serious consideration to how we can promote wellness, well-being and resilience among faculty and students.

Definitions of wellness vary and can be extensive, but for simplicity’s sake, the Merriam-Webster dictionary defines it as “the quality or state of being in good health.” Wellness is also a component of well-being, which comprises not just physical health, but (depending on which definition you use) social, psychological, financial, spiritual, career and other dimensions of health. Resilience is defined as “an ability to recover from or adjust easily to misfortune or change.”

We used the ADEA Joint Council Administrative Boards (ADEA JCAB) annual business meeting at the ADEA offices in Washington, DC, earlier this year to begin discussing how we might foster these qualities in our members. ADEA Chief Policy Officer Denice Stewart, D.D.S., M.H.S.A., organized that meeting, and she will also be presenting on becoming a resilient leader at the 2017 ADEA Sections on Business and Financial Administration and Clinic Administration (ADEA BFACA) Meeting this coming October.

But this is not just a top-down initiative. Wellness, well-being and resilience have also been on the minds of ADEA Council of Faculties members over the past year. Inspired by what they learned at the ADEA JCAB meeting, some of these individuals decided to take action. As a first step, they developed a common understanding of what these concepts are all about and used a portion of their ADEA Annual Session & Exhibition business meeting to share what the literature says on wellness, well-being and resilience with the rest of their Council.

“We wanted people to leave with long-term, short-term and in-the-moment strategies they could employ immediately,” says Sophia Saeed, D.M.D., Associate Professor of Preventive and Restorative Sciences at the University of California, San Francisco, School of Dentistry (UCSF SOD). Sophia took the lead in developing the training. “We wondered,” she told me, “could we take small steps in our own behaviors, in the way we react to certain situations, so that we are better to ourselves and better role models for our students?”

Forty people attended the session and found it useful, as did a smaller group at UCSF SOD, so the Council is now partnering with the ADEA Council of Deans and the ADEA Council of Students, Residents and Fellows to develop new programming with a broader goal.

“This will be more of a dialogue,” Sophia told me. “Depression, burnout, suicide—these things are still stigmatized topics. Our goal for the Annual Session meeting will be to hear about these issues from the perspectives of the students, the faculty and the administrators and to ask, ‘How can we all work together to solve this problem?’”

Sophia believes that everyone, not just those in formal leadership positions, can make a contribution. “The way you behave has an impact on everybody around you. We know that from science,” she says. “A grassroots movement where everyone made a commitment to being kinder to each other, that could really have a huge impact on educational and health care institutions.”

That’s a compelling vision, and individuals who embrace it should find considerable institutional support. In the last year alone, major entities have publicly expressed their concern that stress among health professionals is taking too great a toll on providers and putting the quality of care at risk.

  • The National Academy of Medicine has convened the Action Collaborative on Clinician Well-Being and Resilience to study the problem. Last month, the ADEA Board of Directors approved ADEA’s participation as a sponsoring member. As part of this initiative, I was privileged to be part of an interprofessional group that authored a discussion paper laying out a systems approach to addressing these issues in both education and practice.
  • The Accreditation Council for Graduate Medical Education has begun studying deaths among residents to gain insight into the phenomenon and how it might be prevented.
  • Our sister organization, the Association of American Medical Colleges, convened a meeting to address burnout, depression and suicide among physicians.
  • More than 62,000 people signed a petition calling on medical associations to address the “culture of abuse” that contributes to these problems.
  • The CEOs of 10 health care delivery organizations held a summit, which concluded, “[P]hysician burnout is a pressing issue of national importance for patients and the health care delivery system.” They urged their peers to “embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations.”

These efforts build on earlier work, including an effort by the American Dental Association (ADA) to help practicing dentists build resilience. In the spring issue of the ADEA CCI Liaison Ledger, ADA Executive Director and Chief Operating Officer, Kathleen O’Loughlin, D.M.D., describes her own commitment to fostering wellness among practicing dentists and its relevance for dental students and faculty members. (Two other articles describe related work by our colleagues at the Dental College of Georgia at Augusta University and at the University of Kentucky College of Dentistry.)

I hope by now most of you have heard of the IHI Triple Aim initiative, a framework developed by the Institute for Healthcare Improvement. The framework’s three goals—better patient care, improved population health, and reduced health care costs—have been a beacon for health systems that want to do better. Since 2014, we’ve heard calls for adding a fourth aim: improving the work life of health care providers to address burnout and restore feelings of joy and satisfaction in work. Those calls are growing louder by the day.

It is possible to live with stress and find professional fulfillment, as Kathy’s essay beautifully articulates, but for most people, finding that balance is a challenge. This reality became painfully evident for many in our community with the passing of Jiwon Lee, a predoctoral student at Columbia University College of Dental Medicine who was known to many through her role as President of the American Student Dental Association. And each of us has suffered the loss of other less-familiar individuals as well. I am heartened that our community—and the health professions generally—are now focused on averting future tragedies and restoring balance to the lives of students, residents, fellows, faculty and practitioners. These steps are essential—not just to each individual’s personal health, but to the long-term health of our professions and ultimately, our patients.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic describes recent events that are connecting ADEA with colleagues overseas.

Traveling has long been a part of my job, but this year I’ve had a record number of opportunities to do so on behalf of the Association. In May, I joined more than a dozen other ADEA members in London for ADEE/ADEA 2017—the first truly global gathering of dental educators in a decade, and the first such meeting jointly planned by ADEA and the Association for Dental Education in Europe (ADEE).

The highly interactive meeting drew nearly 300 participants from nearly 50 countries in North America, Europe, Asia, the Middle East and Latin America. Attendees were attracted in large part by the rare opportunity to have a full six hours of protected time for substantive, face-to-face discussions with colleagues from around the globe. Although global networking proved to be the overarching theme for the meeting, the conversation also focused on three other topics of broad concern: interprofessional education, technological and scientific discovery, and assessment.

After returning to the States, I called the President of ADEE, Corrado Paganelli, D.D.S., M.D., Professor and Dean of the dental school at the Università degli Studi di Brescia in Brescia, Italy. He spoke to me from his office before jetting off to a site visit in Israel and then to a conference in Malta. He mentioned that he would be traveling to Oman after that and insisted that continually moving between nations was, for him, a pleasure.

This outlook partially explains why he is such a good ambassador for ADEE and an evangelist for greater uniformity in dental education. As Corrado put it, “Dental students may not use exactly the same device or the same technique, but their training must enable them to practice anywhere in the world.”

Corrado has had a ringside seat as a unified Europe has worked for “dental harmonization,” the process of creating a common approach to dental education in Europe. Previously, the Eastern European nations took a “stomatological” approach (dentistry as a specialty of medicine) while the Western ones were oriented toward “odontology” (dentistry as an independent profession). The politics of Europe may have pushed dentistry to harmonize these approaches across the continent, but once that process was underway, Corrado says, it didn’t make sense to limit their vision of dental education to established European models, an attitude that opened them up to the world.

“There are no more borders in dental education,” Corrado believes. “This is felt everywhere.”

Corrado’s statements certainly capture the aspirations of many in our community, but on the other hand, cross-border encounters also underscore the lack of formal, consistent, international standards for dental education and practice. Each country—and to some extent, each school—is adapting its clinical practices and its curriculum to local conditions, factoring in the economics of dental care delivery, the availability of clinical equipment and materials, the cultural norms of patients and student preferences.

Understanding this context is key to understanding the challenges our colleagues face in other parts of the world. As Corrado put it, “You have to go into detail to understand each other and work on difficulties.”

These comments resonated with my own observations during another recent cross-border experience. In April, several members of the ADEA Board of Directors and senior staff traveled to Havana, Cuba, to look at health professions education and health care in a radically different context. It’s one thing to read about the Cuban health system, but it was quite another to see it in person. I’m not sure we would have understood the critical importance of culture in shaping health care in Cuba without that firsthand view.

For starters, it quickly became clear that Cubans consider health care a right, and because their system is entirely government run, they have highly efficient mechanisms in place for delivering integrated, data-driven care. Neighborhood policlínicos (akin to our community health centers) provide integrated primary care to everyone within a designated geographic area, typically a neighborhood. Physicians, nurses and dentists visit patients in their homes and witness for themselves the environmental and social conditions that influence health.

Because every person in the country has access to the health system, Cuba’s population health statistics are not based on projections but on real numbers. Health professionals use the data they gather to categorize patients by level of need. The Ministry of Health uses this information to distribute resources and make truly informed decisions about everything from where to target anti-smoking campaigns to how many hygienists to train to which neighborhoods need a full-time diabetes educator.

Cuba’s health system is an interesting achievement, especially considering the absence of electronic health records to facilitate this work. Yet, despite universal access to care and a strong emphasis on health education, Cubans still experience dental disease. With tobacco use prevalent, they see plenty of oral cancer. They also lack a fluoridated water supply to suppress dental caries, although a fluoride rinse program in the schools keeps their caries rate somewhat lower than the rate in the United States.

ADEA Chief Policy Officer Denice Stewart, D.D.S., M.H.S.A., asked the director of a clinic we visited what would happen if a parent refused fluoride treatment for their child. The look of absolute horror on her face said volumes about how Cuban attitudes toward public health differ from our own. She was incredulous that any parent would refuse treatment, and looked at the interpreter as though he had misinterpreted the question.

We also witnessed some distinct differences when it came to dental education. All Cuban dental schools are government run, and they use a national curriculum. Students who demonstrate aptitude and complete the necessary prerequisites enter dental school directly from high school and spend five years earning their dental degrees. The last two years are spent in supervised practice in one of the community-based clinics.

We spoke with one of the educators involved in the country’s last predoctoral curriculum redesign. She told us that dental students have clinical experiences similar to our own, but dental education in Cuba is decidedly low-tech compared with what occurs on North American campuses. We didn’t see a lot of digital radiography, computer-aided design and manufacturing (CAD/CAM) or advanced surgical equipment. Yet, despite the lack of digital devices and computerized patient records, the country does have an online network, InfoMED, that gives dentists and other providers across the country online access to all the medical libraries in Cuba and throughout the world.

While Cuba is renowned for sending health care teams to countries around the world, the lack of access to the kinds of supplies we take for granted—from dental implants to everyday items such as sutures, prescription drugs and even toilet paper—can frustrate the ability of health professionals to deliver care. We witnessed efforts by one charitable organization to alleviate these shortages, which many attribute to the U.S. trade embargo that has been in effect since 1960.

Given these material needs, it’s easy to imagine how Cuban dental schools might benefit from enhanced cross-border collaboration, and there are also ways we might benefit from continued engagement with our Cuban colleagues. Learning from their use of community-based rotations to enhance students’ understanding of community service and population health is one example that immediately comes to mind, but how we might facilitate such an exchange beyond this initial visit remains to be seen. Even with more established relationships, sustaining the flow of ideas and know-how across international borders can be challenging.

In London, for instance, attendees expressed interest in finding a global mechanism dental educators could use, whether to share resources or to communicate with colleagues about enhancing faculty development, building a curriculum and creating environments that support competency-based education.

Patrick Ferrillo, Jr., D.D.S., Past President of the ADEA Board of Directors and longtime leader in our work, was one of the people who facilitated the discussion in London about global networking. As he noted, dental educators do have one model for global cooperation: the International Association for Dental Research (IADR). That organization has a strong network that has been able to bring colleagues throughout the world together for regional and global meetings, and IADR provides additional ways for members to correspond with one another between face-to-face encounters. “That does not exist on the education side,” Pat rightly points out.

Pat has been involved on the global stage for years, and left the last global congress—a summit in Dublin, Ireland, organized by ADEA in collaboration with ADEE and the International Federation of Dental Educators and Associations (IFDEA)—energized by the prospect of a globally connected community of dental educators. But, he says, tangible activity to translate that goodwill into a global infrastructure to serve as an umbrella for international exchange must begin to take shape.

“Right now, there are no resources out there, and that’s the real challenge,” Pat remarked when we spoke. While researchers can use their research dollars to attend IADR meetings, educators lack a comparable source of funding. Those from the best-resourced schools often find other ways to underwrite their travel; government sometimes helps (participation in the Dublin summit was underwritten in part by a grant from the European Union, for instance); and corporate sponsors typically play a key role in making professional gatherings possible. Indeed, the London meeting would not have been possible without the contributions of our gracious host, King’s College London Dental Institute, and the support of ADEA Corporate Partners Colgate-Palmolive Co. (Colgate Oral Health Network); GlaxoSmithKline Consumer Healthcare; Henry Schein, Inc.; and The Procter & Gamble Company (Procter & Gamble Professional Oral Health); and additional support from FollowApp.Care, LM-Dental, Planmeca, Two-Ten Health Limited, and Liftupp.

A decade from now, we may look back at this period as a watershed for global cooperation in dental education. As I write this, ADEA staff are engaged in our next international foray. A team travelled to Québec City this week to follow up on the initiatives we first discussed last November in Montréal with Canadian dental school deans (see the March 2017 issue of Charting Progress).

Next stop after that, who knows? ADEA has been making a conscious effort to reach out to the global dental education community for some time now (see the October 2016 issue of Charting Progress). And I have no doubt ADEA’s strategic commitment to serve as a collaborative partner in the global effort to improve oral and overall health will continue to blossom in the years ahead.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic describes a new ADEA initiative that takes the long view—engaging today’s students to eventually fill the faculty pipeline.

In 2016, the ADEA Board of Directors approved an initiative to encourage and expand the establishment of ADEA Chapters for Students, Residents and Fellows. At last count, 30 U.S. dental schools had chapters, and eight more schools had plans to create one. Most chapters are quite young, with the majority established in the last five years. As of yet, there are no formal chapters in Canada, but ADEA has set a goal of establishing a chapter at every North American dental school, and the ADEA Council of Deans has created a working group to help ensure that this happens.

What do we hope these chapters will accomplish? Their primary purpose is to promote student interest in academic careers, or as one chapter founder put it, become “the group at every dental school that tells the story of how great a career in academic dentistry is and how accessible that career can be for anyone who wants to pursue it.” That is the vision of Tim Treat, D.D.S., who started an ADEA chapter at the Indiana University School of Dentistry (IUSD) in 2014.

Tim graduated last year and currently serves as the ADEA Board Director for Students, Residents and Fellows. He likes to tell the story of what started him down the path toward academic dentistry. In 2013, the IUSD Dean of Students reached out to the school’s class presidents to see if any were interested in attending the ADEA Annual Session & Exhibition. Unlike his peers, Tim said, “Yes.”

“So I’m this first-year dental student, on my own, flying to Seattle, and a couple days later I’m at the ADEA Gies Awards sitting next to the Dean of the dental school and seeing the celebration of amazing things people were doing all over the country to make dental education better,” he recalls. That interaction with faculty and administrators in that environment hooked Tim on the idea of an academic career, and his exposure to the ADEA Council of Students, Residents and Fellows (ADEA COSRF) helped him see how an ADEA chapter might help make that possible. He returned to Indiana, enlisted the support of classmate Mackenzie Kelley, and together they worked to create an ADEA student chapter at IUSD.

Today, that chapter is going strong. It hosts the school’s annual Dental Day for prospective students, and its Last Lecture series, where retiring faculty members tell their stories, is among the best-attended events at the dental school.

“Tim has really been able to bring ADEA to life for our students,” says John Williams, D.M.D., M.B.A., the Dean at IUSD. “The students have now gone on to become involved in additional aspects of ADEA. In fact, the current COSRF chair is an Indiana third-year student, Allison Williams.”

IUSD faculty and administrators also report that students have begun approaching them to learn about academic careers since the school formed its chapter two years ago. Tim is not surprised. During his tenure as an ADEA Board Director, Tim has learned about the great need for dental educators in the face of pending retirements. He sees this as an opportunity for his generation to “get into faculty positions and make a difference,” and he believes the timing couldn’t be better.

“More and more students each year will never own their own practices. Academic dentistry is an alternative with many benefits,” Tim says. He is clearly convinced of that. He is currently in a general practice residency at the Veterans Administration hospital in Indianapolis. Once completed, he intends to return to his alma mater to teach, and thanks to John Williams, a wonderful new transitional appointment awaits him.

“A year ago I created a clinical fellowship program for prospective faculty who had recently graduated,” John told me. The two-year fellowship will allow students who have completed a general practice residency or AEGD program to continue to develop their clinical skills and an academic portfolio. They’ll learn about teaching, assessment, curriculum management, accreditation—even the finances of dental education. “It will be a robust exposure to what it means to be an academic,” John says.

Recent events at IUSD represent exactly the types of developments we need in order to ensure that the next generation is ready to step into our shoes. It is estimated that only 4% of students need to go into academia to solve the future faculty problem. In other words, if two or three graduates from each dental school were to follow Tim’s path, those projected faculty vacancies that keep us up at night would disappear. The first step is to make sure that students know about ADEA and are aware that academic careers are an option.

“Every academic institution has an opportunity, if not a responsibility, to engage their students in this option,” John believes. “The more we can talk to students early on and get them good role models, the more I think you’ll have a significant improvement in faculty recruitment and retention.”

One of those role models is Jennifer Perkins, D.D.S., M.D., Assistant Professor in the Department of Oral and Maxillofacial Surgery at the University of California, San Francisco, School of Dentistry (UCSF SOD). She is also the winner of this year’s ADEA/ADEA Council of Students, Residents and Fellows/Colgate-Palmolive Co. Junior Faculty Award.

Jennifer is nothing if not approachable. She remembers that as a resident, she was always the one that people would come to with questions. As one of the newer full-time faculty members at UCSF SOD, she’s developed a similar reputation.

“It didn’t take very long after my getting here in 2014 for word to get out that I was someone students could come to,” she says. Today, Jennifer’s reputation as an oral surgeon, academic, parent of four, and go-to person for advice on dental career decision-making even draws occasional calls from students on other campuses.

“I’m not a guru who knows the answers to everything,” she says, “but you know, being willing to put time in with students, that makes an impression.”

Many faculty take the time to mentor students, but junior faculty, perhaps by virtue of their relative youth, tend to be especially effective role models. Jennifer had a mentor of her own who provided the support and reassurance that she would be a good candidate for oral surgery. Her decision to pursue an academic career came later.

“I didn’t know that was going to be my career necessarily until another faculty member here in my training program told me on multiple occasions—just out of nowhere—‘You’re really meant to do academics and be a teacher.’”

When she did start teaching part time, she says it became “obvious” to her as well that she needed to become an educator. “I get equally, or more, excited about teaching as about all the other parts of my job. So I think if I was in private practice, I would really be missing out on one of the things that kind of gives life to my career: getting to interact with the next generation.”

The students in UCSF SOD’s ADEA Student Chapter nominated Jennifer for the ADEA Junior Faculty Award. ADEA at UCSF SOD is one of the largest and most active ADEA chapters. In existence for more than 10 years, it hosts outreach events for high school and college students, two lunch and learn series and tutorial sessions for dental students, and faculty/student mentorship programs—one for first-year students, and another through the ADEA Academic Dental Careers Fellowship Program (ADEA ADCFP). Not surprisingly, UCSF SOD has now received an ADEA Distinguished Chapter Award five years in a row!

This month, ADEA will unveil the ADEA Chapter Toolkit for Students, Residents and Fellows at the first-ever ADEA COSRF Leadership Orientation to be held here in Washington, DC. The toolkit is a dynamic resource intended to help ADEA Student Chapters cultivate interest in academic dental careers. It includes information and resources to guide chapter creation, member recruitment, fundraising and planning events that will raise awareness of academic dental careers.

“It’s a matter of putting this on the radar screen and letting students make their own decisions,” John Williams believes, “but it’s far easier to do it when you have a strong ADEA Student Chapter and people know why it’s there.”

I couldn’t agree more.