A Comparison of Private and Public Dental Students Perceptions of Extramural Programming

A Comparison of Private and Public Dental Students Perceptions of Extramural Programming Curt S. Ayers, D.D.S., M.P.H.; Richard A. Abrams, D.D.S., M.P.H., M.Ed.; Michael D. McCunniff, D.D.S., M.S.; Benjamin R. Goldstein Abstract: This project was undertaken to compare the opinions of private and public dental school students perceptions concerning extramural programming, which is defined as any aspect of the curriculum in which undergraduate dental students provide dental care outside the main dental facility. A survey instrument was used to collect data from undergraduate students at a private (N=267; 88.4 percent response rate) and at a public (N=213; 67.2 percent response rate) dental school. When asked to rate the value of various extramural sites in making them a better dentist, both groups rated private dental offices the most valuable and prisons the least valuable. When questioned about the amount of time students should spend each year in extramural programming, private students, overall, desired 34 percent more time than did public students. When asked what percentage of the total time spent in extramural programming students should spend providing various categories of dental care, public school students thought 26 percent more time should be spent rendering preventive services/health education than did the private students. The private students indicated a stronger desire (13 percent more) for rendering clinical services than did public students. Both private and public students were most likely to enter group private practice after graduation. The increasing interest in community-based programs makes the information gained from this study useful for future curriculum planning. Dr. Ayers is Associate Professor, Division of Public Health Dentistry, Marquette University School of Dentistry; Dr. Abrams is Associate Professor and Head, Division of Public Health Dentistry, Marquette University School of Dentistry; Dr. McCunniff is Associate Professor, University of Missouri-Kansas City School of Dentistry; and Mr. Goldstein is a Research Assistant, University of Wisconsin. Direct correspondence and requests for reprints to Dr. Curt Ayers, Division of Public Health Dentistry, Marquette University School of Dentistry, P.O. Box 1881, Milwaukee, WI 53201-1881; 414-288-6022 phone; curt.ayers@marquette.edu. Key words: dental education, extramural programs, community-based programs, off-campus programs, public health programs Submitted for publication 10/18/02; accepted 1/24/03 In recent years, there has been growing interest among dental educators concerning the opportunities offered by community-based dental programs. 1 In part, this interest has arisen because many dental schools have found it difficult to maintain the staffing, space, and equipment necessary to operate their clinical education programs. 2-4 Unfortunately, these problems are not likely to diminish anytime soon, particularly after the budget shortfalls and tough economic times following September 11, 2001. Other factors having an influence on dental education have been increasing societal pressure on dental schools to provide dental care for the underserved and the growing demand from dental students for clinical experiences in real world settings. 5 Dental education is far from unique: other health care professions are also becoming more interested in community-based education. 6 National and international bodies recently have advocated expanding professional health care education into community-based education. 7-15 Two of these reports have called for fundamental changes in the clinical training of dentists. 7,8 In November 2001, the Robert Wood Johnson Foundation announced a new program focused on changing dental education and improving access to dental care for low-income populations. Funding through the six-year, $19 million Pipeline, Profession, and Practice: Community-Based Dental Education initiative was available for up to ten dental schools. These schools were to develop communitybased clinical programs designed to expand their patient care and become better able to provide care for underserved populations. The foundation suggested dental schools consider a number of different education sites, such as private dental offices, community health centers, public and parochial schools, and hospitals, so that dental schools would have adequate capacity to participate in providing care for the underserved. The Robert Wood Johnson Foundation probably was motivated, in part, by the Surgeon General s Report on the Oral Health of the Nation released in May 2000 16 and a Feasibility Study conducted by Howard L. Bailit and funded by the Macy Founda- 412 Journal of Dental Education Volume 67, Number 4

tion. The December 1999 issue of the Journal of Dental Education contained findings from the Feasibility Study along with descriptions of communitybased clinical programs at several U.S. dental schools. The Journal of Dental Education has published additional articles on community-based programs, 17,18 which have directed attention to some of the issues surrounding these programs. However, very little information is available regarding students perceptions. Students perceptions of a program s value are essential for planning a successful community-based experience. In anticipation that their schools would be in a position to strengthen or expand their communitybased programs, faculty members from a private and a public dental school began to collaborate. Of primary concern to these faculty members were students reactions and perceptions about any future community-based programs. The purpose of the study was to explore factors that could influence students acceptance of potential extramural programming included type of site, time commitment, and availability of clinical opportunities at a site. Methods The objective of this study was to compare the perceptions of undergraduate students at a private dental school with the perceptions of undergraduate students at a public dental school regarding the value of various aspects of extramural programming to their competency. A questionnaire was developed, pretested, and administered to undergraduate students at a private dental school (N=267; 88.4 percent response rate) and to undergraduate students at a public dental school (N=213; 67.2 percent response rate). The survey was administered to all students during didactic class time. All students had already been involved in prior extramural programs, with their involvement increasing as they progressed through the curriculum. For this survey, an extramural program was defined as any aspect of undergraduate dental education in which students provided dental care to individuals in settings outside the main clinical facility of the school. Approval from each institution s Human Subjects IRB Committee was obtained prior to the study. The survey asked students to rate the perceived value, on a 5-point Likert scale (ranging from 1=no value to 5=very valuable), of how they thought various extramural sites would enhance their competency. The sites they were asked to rate were: mobile van, private dental office, hospital clinic, private community health center clinic, nursing home, and prison. Prior to this study, we surveyed other dental schools to identify what types of extramural sites were available to students. That survey produced the sites listed. It should be noted that both schools did not have all these sites currently available for students. Rather, the study examined various possible sites, all of which had the potential to become extramural sites. The questionnaire also asked how many weeks dental students thought they should spend in community-based educational experiences during each academic year. Furthermore, the questionnaire asked the amounts of time, of the total time spent in extramural programs, students thought should be devoted to specific categories of dental activities. There were three categories of activities: preventive/health education, clinical services, and needs assessment. The first category preventive dentistry services consisted of dental prophylaxis, fluoride treatment, and sealants; health education services consisted of instruction on effective brushing, flossing, diet, and nutrition habits. The second category clinical services included basic clinical services and comprehensive clinical services. Basic clinical services included the provision of uncomplicated operative or periodontal treatment, oral surgery procedures, and emergency care. Comprehensive clinical services included the provision of all services in all disciplines typically provided by dental students. The third category needs assessment consisted of determination of the dental neglect, treatment, and resource needs of a site. Lastly, the questionnaire asked students about their postgraduation plans. Results Student preferences for extramural locations are displayed in Table 1. When asked to rate on a 5- point Likert scale how valuable (1=no value, 5=very valuable) students participation at various extramural sites might be in making them a better dentist, private dental offices received the highest mean scores from both private and public dental students (private=4.79, public=4.71), whereas prisons received the lowest mean scores (private=2.67, public=3.04). Analysis by t-test demonstrated a significant difference in the perceived value of hospital clinics, community health centers, and prisons between the two groups of students. April 2003 Journal of Dental Education 413

Table 1. Student preferences for extramural sites, using a Likert scale (1=no value and 5=very valuable) Private Public Dental Students Dental Students Category of Site Mean and (SD) Mean and (SD) Mobile Van 3.60 (1.28) 3.62 (1.63) Private Office 4.79 (.55) 4.71 (.64) Hospital Clinic 1 4.43 (.86) 4.25 (.93) Community Center 2 4.45 (.80) 4.25 (.92) Nursing Home 3.48 (1.09) 3.40 (1.15) Prison 3 2.67 (1.32) 3.04 (1.25) 1 t=2.19, df=477, p=.029 2 t=2.51, df=476, p=.012 3 t=3.09, df=477, p=.002 Table 2. Mean number of weeks students indicated they should be involved in extramural dental programs Private Public Year in Dental Students Dental Students Dental School Mean and (SD) Mean and (SD) D1 2.30 (5.68) 1.62 (1.52) D2 1 3.40 (5.46) 2.25 (2.60) D3 2 5.56 (6.03) 4.26 (3.74) D4 3 6.74 (6.33) 5.46 (6.11) Total Weeks 4 17.52 (20.08) 13.08 (12.61) 1 t=2.72, df=448, p=.007 2 t=2.86, df=447, p=.004 3 t=2.14, df=444, p=.032 4 t=2.74; df=463, p=.006 Table 2 displays the data comparing the opinions of private and public dental school students regarding the number of weeks that should be spent in extramural programming in each year of dental school. In response to this question, private dental school students consistently indicated more weeks than did public dental students. Use of a t-test to compare means demonstrated no significant difference in the number of weeks students thought first-year students should spend in the community. However, there were significant differences for each of the other three years of dental school as well as total weeks. Regarding total weeks in extramural programs, private students desired 34 percent more time than did public students. Students preferences for time allocation at extramural sites are shown in Table 3. When asked what percentage of the total time spent in community-based programs students should spend providing specific categories of dental care, public dental school students thought 26 percent more time should be devoted to rendering preventive services and health education than did the private dental school students Table 3. Percentage of total extramural time students thought should be spent in various extramural activities Private Public Type of Dental Students Dental Students Extramural Service Mean and (SD) Mean and (SD) Health Education 1 11.50 (7.47) 14.96 (9.82) Preventive Services 2 14.34 (7.72) 17.66 (9.59) Needs Assessment 13.09 (8.25) 13.72 (6.84) Basic Clinical Services 3 37.04 (17.86) 33.06 (16.01) Comprehensive Clinical Services 4 23.95 (15.14) 20.66 (14.51) 1 t=4.27, df=453, p<.001 2 t=4.08, df=453, p<.001 3 t=2.47, df=456, p=.014 4 t=2.30, df=445, p=.021 (private=25.84 percent, public=32.62 percent). The private dental school students had a 13 percent stronger desire for rendering clinical services than did public dental school students (private=60.99 percent, public=53.72 percent). The desired percentage of time allocated for needs assessment at extramural sites was about the same for both groups (private=13.09 percent, public=13.72 percent). Use of the t-test to compare means demonstrated that, except for needs assessment, all other categories were significantly different. Table 4 illustrates the private dental school and the public dental school students postgraduation plans. Group private practice was the most commonly selected preference for both private and public dental students. Among the other postgraduation options, graduate school was second, solo private practice third, and the military/public health service fourth. There was a significant difference between private and public dental students postgraduation plans (Chi square=11.05; df=4; p=.026). Discussion When examining the data, readers should keep in mind that this study presents students perceptions Table 4. Students postgraduation plans (D1, D2, D3, D4) by percentage What Students Planned to Do Private Public Postgraduation Dental Students Dental Students Solo Private Practice 15.0 percent 17.4 percent Group Private Practice 41.6 percent 37.6 percent Military 14.2 percent 10.8 percent Graduate Program 25.8 percent 23.9 percent Other 3.4 percent 10.3 percent Chi square=11.05; df=4; p=.026 414 Journal of Dental Education Volume 67, Number 4

of the value of various aspects of extramural programming to their competency. This does not suggest that all the aspects surveyed are currently in place at both schools. In addition, although this study compared a private and a public dental school, it is not reasonable to assume that these private and public schools are representative of all private and all public dental schools. The data demonstrated some significant differences in students perceptions of extramural programming between the private and the public dental school. The objectives of the study did not include exploration of the reasons for these differences; our interest in determining if differences existed was the genesis of our study. Still, we can assume that several factors could contribute the differences. The student bodies of both of these schools may not have been drawn from the same pool, and entering students expectations may be different at a private and a public dental school. Differing resources, constraints, and faculty also could contribute to these differences, not to mention differences in schools missions and goals. Further investigation will be needed to determine why private and public dental students in this study had somewhat differing opinions. Adequate planning and thought are critical for success when developing any extramural curriculum. When dental educators discuss extramural programming, several important questions need to be addressed: 1. What types of experiences are appropriate for students and how can each become an integral part of the curriculum? 2. In what community-based activities should D1, D2, D3, and D4 students be engaged, and how much time should be allocated for each activity? 3. What location and activity choices should be available for students, particularly seniors? 4. What factors might limit student participation; that is, must students qualify before involvement in extramural programs? 5. What are the qualifying criteria for distant sites, faculty, etc.? Since an overriding goal of extramural programming should be to ensure that there is proper emphasis on providing dental care to underserved populations, it would be prudent to begin students experiences with the underserved early in their dental school careers. One of the realities confronting dental educators is the recognition that the bulk of didactic course material is given in the D1 and D2 years; thus, limited time may be available to devote to extramural programming during these years. Additionally, as students advance, they become more productive clinically. Therefore, D3 and D4 students are able to provide far more comprehensive dental care to the underserved than are D1 and D2 students. It would seem reasonable that D3 and D4 students should be at a clinical site for at least a fourweek period to enhance their learning. Typically, when a student visits a site, it takes about a week to become familiar with the paperwork, clinical routine, etc. Being at a site for less than four weeks means that the student will not be able to follow many of his or her patients to completion and see the ultimate results of treatment. For the D1 and D2 students, their experiences should be varied; it may not be possible for each student to spend all of his or her time at one location. In fact, it is desirable for the D1 and D2 students to be exposed to a variety of sites, so that they can make an educated decision about their placement when they become D3 and D4 students. Dental students should be able to participate actively in selecting their clinical extramural placement. A menu should be available for students to select their choice of extramural site. A system should be in place at the sites to ensure that a student s skills match the needs of the patients, for both the student s and patient s benefit. It should be recognized that not every site might provide all possible treatments. Having students participate at more than one site should ensure that all students gain experience with all treatments. However, a system should be in place that will equalize student placements so no site is left unattended. As much as possible, extramural programming should be in sites that provide care to the underserved. There are various potential externship sites: community health centers, hospitals, Indian reservations, nursing homes, school clinics, and private dental offices. Although at present many state dental boards will allow students to do an externship only in the state where they are enrolled in dental school, there should be some provision to allow students to participate in externships in a state of their choosing. This is a critical item, as typically students in dental schools come from various states and ultimately will practice in other states. In some states, there are legal issues (including liability insurance) that will need to be resolved before externships become a reality. Dental educators as well as organized dentistry April 2003 Journal of Dental Education 415

should work together to develop a national plan to facilitate this. There are distinct advantages in having dental students involved in private dental offices. This study revealed that these offices are students first choice for extramural placement. The results also revealed that 56.6 percent of private and 55.0 percent of public students said that, upon graduation, they would enter solo private practice or group private practice. In addition, 25.8 percent of private and 23.9 percent of public students intended to enter a graduate program, and many of them ultimately will enter private dental practice. Having dental students participate in externships in private practices gives them direct experience in practice management a discipline often difficult to teach in a dental school. Starting any new program may or may not entail costs. However, every dental school s budget and financial situation are unique. Having dental students involved in extramural programming should enable schools to adjust the number of their faculty. As fewer dental students are in the school s clinic, there should be a need for fewer faculty. Additionally, some of the educational overhead costs should be reduced when students are engaged in extramural programs. On the other hand, there will be a reduction in income generated from students providing dental care in the school s clinic. The savings generated by sending students out into the community must offset the revenue they would have generated by working inside the dental school for a program to be cost-free. As more extramural programs are introduced, their budget impact can be determined. More important, however, is the issue of the dentally underserved. Many of the patients who qualify for Medicaid have difficulty obtaining dental care. Having dental students providing care for the underserved would significantly expand the number of providers. One would assume that, given a choice, most Medicaid patients would prefer having their care provided in a private office rather than in a public clinic. Having dental students providing care in private dental offices would help to accomplish this. Furthermore, dental students could be placed geographically and dental offices could be selected based upon the underserved needs in a particular area. When discussing any kind of community-based programming, one of the questions that arises is what level of students should be providing which services. The range of dental services that students could provide for patients should depend upon the student s academic year, as well as the student s clinical skills. In addition, each student should be certified as qualified in each particular discipline before being permitted to perform procedures in that discipline extramurally. The decision of what extramural activities would be appropriate for dental students will vary from school to school. Activities will differ as every school has its unique curriculum. Students at one school may be prepared for some activities earlier or later than at another school, depending upon course sequencing. We have developed (Table 5) a potential timetable showing, generally, which specific activities could be possible for each academic year in a curriculum. There is no question that every dental school has its own priorities and needs. It would be impossible to find one curriculum appropriate for every school: there is no magic formula that will work for all. However, there are certain basic concepts in the development of extramural education programs for dental students. First, programs must be perceived as useful and valuable to the students. This is an extremely important factor for the viability of any extramural program. Second, programs should provide care for the underserved. It is a fact that there is a large number of dentally underserved patients, and students should be made aware of this not only in the classroom, but with their own eyes. In addition, as with any other program in a dental school s curricu- Table 5. Possible extramural activities appropriate for D1, D2, D3, and D4 dental students D1 D2 D3 D4 Health education in schools, day care/head Start centers, nursing homes, etc.; dental assisting inside the school in the first semester and outside the school in the second semester; take a medical and psychosocial history of patients Can do all of the activities listed for D1 students, as well as: prophys, sealants, fluoride treatments, basic operative and periodontics; community outreach as needed in specific communities (school-based, health department, etc.); dental assisting when necessary Can do all activities listed for D1 and D2, as well as: intermediate clinical services (operative, periodontics, simple endodontics, emergency treatments, and some comprehensive treatment) Can do all activities listed for D1, D2, and D3, as well as: comprehensive clinical services, periodontal surgery, fixed and removable prosthodontics, more advanced endodontics, and basic oral surgery 416 Journal of Dental Education Volume 67, Number 4

lum, program evaluation is essential. All dental school programs must relate to the school s mission, goals, and competency statements in its curriculum, and these factors must be kept in mind in extramural program development. These issues become particularly important for a school to be successful in the ADA accreditation process. We are convinced that extramural dental education must not be perceived as simply an add-on in a curriculum, but as a necessary and integral component of any contemporary dental curriculum. Most of all, the opinions and views of the dental students involved must be considered for any extramural program to be successful. REFERENCES 1. Bailit H. Community-based clinical education programs. J Dent Educ 1999;63(12):868-72. 2. Myers DR, Zwemer JD. Cost of dental education and student debt. J Dent Educ 1998;62(5):354-60. 3. Kennedy JE. Building on our accomplishments. J Am Dent Assoc 1999;130(12):1729-35. 4. Hardigan J. The costs and financing of dental education. J Dent Educ 1999;63(12):873-81. 5. Jacobson JJ, Kotowicz WE, Turner DF. University of Michigan school of dentistry s community practice. J Dent Educ 1999;63(12):964-8. 6. Seifer S. Service-learning: community-campus partnerships for health professions education. Acad Med 1998;73(2):273-7. 7. Institute of Medicine Committee for the Study of the Future of Public Health. The future of public health. Washington, DC: National Academy Press, 1988. 8. Pew Health Professions Commission. Health professions education for the future: schools in service to the nation. San Francisco: Center for the Health Professions, 1993. 9. Rivo ML, Satcher D. Improving access to health care through physician workforce reform: directions for the 21 st century. JAMA 1993;270:1074-8. 10. Field MJ, ed. Dental education at the crossroads. Report of the Institute of Medicine. Washington, DC: National Academy Press, 1995. 11. Rivo ML, Jackson DM, Clare FL. Comparing physician workforce reform recommendations. JAMA 1993;270:1083-4. 12. Showstack J, Fein O, Ford D, et al. Health of the public: the academic response. Health of the Public Mission Statement Working Group. JAMA 1992;267:2497-502. 13. Rivo ML, May HL, Karcoff J, Kindig DA. Managed health care: implications for the physician workforce and medical education. Council on Graduate Medical Education. JAMA 1995;274:712-5. 14. Boelen C. Medical education reform: the need for global action. Acad Med 1992;11:745-9. 15. Schmidt HG, Neufeld VR, Nooman ZM, Ogunbode T. Network of community-oriented educational institutions for the health sciences. Acad Med 1991;66:259-63. 16. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. 17. Skelton J, et al. University of Kentucky community-based field experience: program description. J Dent Educ 2001:65(11):1238-42. 18. Ayers CS, Abrams RA, Robinson M. U.S. and Canadian dental school involvement in extramural programming. J Dent Educ 2001;65(11):1272-7. April 2003 Journal of Dental Education 417