Increasing Student Diversity and Cultural Competence as ... - CiteSeerX

Increasing Student Diversity and Cultural Competence as Part of Loma Linda University School of Dentistry’s Service Mission Margie R. Arnett, M.S.; Ron Forde, D.D.S., M.S.D. Abstract: For many years, studies have identified a need for greater racial and ethnic diversity among dental professionals. However, the ability of the field to collectively address the problem has been hindered by the low numbers of underrepresented minority students who apply to dental school. Over the past two decades, college attendance rates have increased and U.S. dental school applications have tripled, but the number of underrepresented minority dental applicants has remained about the same. With the increasing diversity of the U.S. population and specifically that of the state of California, the dental workforce would be enhanced by the presence of more underrepresented minority dentists. Additionally, curricular changes should be implemented to better prepare dental students to meet the oral health care needs of diverse populations. There is general agreement that these workforce and curricular changes would enhance access to care for underserved populations. For seven years, Loma Linda University School of Dentistry participated in the Pipeline, Profession, and Practice: Community-Based Dental Education program. The first phase of this national program addressed deficiencies in diversity in dentistry and in access to oral health care. In the second phase, Loma Linda University continued to collaborate with other California dental schools on specific state initiatives. This article provides an overview of the school’s efforts to enroll a more diverse student body, enhance all its students’ cultural competence, and expand care to underserved populations. Prof. Arnett is Assistant Professor, Loma Linda University School of Dentistry; and Dr. Forde is Assistant Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry. Direct correspondence and requests for reprints to Prof. Margie Arnett, School of Dentistry, Loma Linda University, 11092 Anderson Street, Prince Hall 5518, Loma Linda, CA 92350; 909-558-7283 phone; 909-558-0483 fax; [email protected]. Keywords: diversity, access to care, community-based dental education, community dentistry, dental school curriculum, underrepresented minorities, dental students Submitted for publication 6/20/11; accepted 10/27/11

F

or many years, studies have identified a need for greater racial and ethnic diversity in the field of dentistry.1-5 However, the ability of the field to collectively address disparities has been hindered by the low numbers of underrepresented minority (URM) students who apply to dental school. Over the past two decades, college attendance rates of URM students have increased6 and U.S. dental school applications have tripled,7 but the number of URM dental applicants has remained about the same.7 Because of the growing diversity of the U.S. population and especially that of the state of California, the dental workforce would be enhanced by the presence of more URM dentists. Additionally, curricular changes should be implemented to better prepare students to meet the oral health care needs of diverse populations.3 There is general agreement that these workforce and curricular changes would enhance access to care for underserved minorities. Not only is California the most populous U.S. state, but its anticipated population growth of 12 mil-

June 2012 ■ Journal of Dental Education

lion more residents by 2030 will magnify the need for accessible oral health care services.8 Currently, more than 100 million people in the United States lack dental insurance, and government-funded dental programs are not solving the access challenge due to low reimbursement rates.9 The Medi-Cal program has traditionally provided financial assistance to many California residents in a variety of medical situations. However, on July 1, 2009, California law was changed due to the state’s economic crisis, and most adult dental services were eliminated as a Medi-Cal benefit. Even prior to 2009, the DentiCal participation rate among California dentists was low compared to other states, as was the number of dentists who volunteer at community clinics.10 Consequently, community dental clinics that provide care for those lacking insurance or without the financial means to access traditional practices have long waiting lists for appointments. In 2007, two children received national attention after they died from complications due to untreated tooth infec-

721

tions associated with the difficulty of access to oral health care.11 Loma Linda University School of Dentistry is located in the city of Loma Linda, CA, and has a significant patient base coming from San Bernardino County. In 2010, the U.S. Census Bureau reported that San Bernardino County’s population was 2,035,210, making it the largest geographic county and the twelfth most populated county in the United States.12 Over the past decade, Loma Linda University School of Dentistry participated in the Pipeline, Profession, and Practice: Community-Based Dental Education program. This national program was designed to address the need to increase diversity in dentistry as well as to improve access to oral health care. The Pipeline program, initiated by the Robert Wood Johnson Foundation ($23 million) in 2002 and joined by The California Endowment ($14.3 million), had three main objectives: 1) to significantly increase the number of URM students recruited into dentistry, 2) to develop or improve dental schools’ cultural competency curricula, and 3) to increase the number of days dental students spend at community clinics and increase the number of off-campus sites collaborating with dental schools. All the dental schools in California participated in the Pipeline program, thus providing the possibility of significant improvements in the delivery of dental care in California. People without dental insurance typically seek oral health care less often than recommended and may suffer poor oral health as a result. The extent of dental coverage is substantially lower than medical insurance coverage.13 One approach to bridging this gap is the participation of dental schools and their students in community-based dental education (CBDE), although each school’s involvement in CBDE is based on its own resources, curriculum, and

philosophy of education.14-18 The motto at LLUSD is “Service Is Our Calling,” and the school has a fiftysix-year history of providing pro bono services for local communities and a fifty-four year history of doing the same at international locations. The school’s founding dean, M. Webster Prince, was enthusiastic about providing service to local communities and encouraged faculty members to accompany students to off-site locations and provide free service to populations without access to dental care.19 This article provides an overview of LLUSD’s efforts—motivated by its service mission and expanded through its involvement in the Pipeline program—to increase its number of URM students and prepare all its students to practice in diverse environments.

URM Student Recruitment Loma Linda University School of Dentistry has increased its number of underrepresented minority applicants, students accepted, enrollees, and graduates over the past decade (Table 1). This success is the result of efforts in a number of areas.

Admissions Process and the Role of Faculty Members The Admissions Committee uses a whole-file review process to assess applicants’ promise for success in dental school, and additional attention is given to URM candidates’ files. The whole-file review process seeks to assess an applicant’s achievements and personal qualities for compassion, service, leadership skills, and motivation. The process includes reviewing the application, transcripts, Dental Admission Test (DAT) scores, letters of recommendation, applicant statement, volunteer activities, and shadowing experience in dental offices. The committee also

Table 1. Underrepresented minority (URM) dental students and graduates of Loma Linda University, 2002–03 through 2009–10

2002–03 2003–04 2004–05 2005–06 2006–07 2007–08 2008–09 2009–10

URM applicants 77 92 110 136 163 172 173 145 URM students accepted 7 13 11 11 18 19 18 11 Post-baccalaureate enrollment n/a n/a 3 3 5 4 5 4 Number enrolled from post-baccalaureate n/a n/a n/a 2 1 4 2 4 to dental school Total URM enrollment 3 5 11 10 5 11 11 7 Number of post-baccalaureate graduates n/a n/a n/a n/a n/a n/a 2 1 Total URM graduates 4 8 9 9 9 10 7 6

722

Journal of Dental Education ■ Volume 76, Number 6

considers each applicant’s educational opportunities, challenges, special circumstances, hardships, persistence, and life experiences. The Admissions Committee is comprised of approximately twenty members. Once named to the committee, faculty members can remain on it for three years and must then rotate off for at least one year. The size of the committee and the rotation system for membership encourage broad participation in and support for admissions priorities across the school. During the first year of the Pipeline program, Dr. Charles J. Goodacre, dean of the School of Dentistry, determined that the recruitment of minority faculty members was critical to the enrollment and retention of URM students. On the strength of that decision, the school recruited and employed two minority scientists who held Ph.D. degrees and matriculated them through dental school, an approximately $500,000 investment. These faculty members now teach basic science courses for first- and second-year students, enhancing both faculty diversity and correlation of the basic sciences with clinical dentistry. In addition, students experience faculty diversity early in their dental education. The Pipeline program national evaluation team concluded that the financing of dental education for the two minority scientists was an innovative and effective model.20 In spite of these efforts, finances are a significant challenge that LLUSD faces in its efforts to recruit a student population that reflects the demographics of its county and nation. The school awards partial scholarships to individual students through its scholarship endowment funds. Unfortunately, endowed funds are not sufficient to provide full scholarships, and some URM students who were accepted to LLUSD have chosen other dental schools for financial reasons.

coursework prior to applying to dental school. It is now a generally accepted practice at LLUSD to inform and mentor students from the surrounding areas concerning a career in dentistry during their junior and senior high school years. In addition, the LLUSD Office of Admissions operates six outreach programs, four of which are dedicated to URM students. The Careers in Dentistry Workshop, held each July, provides an opportunity for undergraduate students to spend several days at the school. During the workshop, students participate in seminars given by faculty from multiple departments, shadow students in the clinic, and spend time in the laboratory developing hand skills. LLUSD provides scholarships to this program for up to two URM students. The scholarship covers the cost of travel, tuition, room, and board. LLUSD supports a similar summer enrichment program for African American high school students called Minority Introduction to Health Sciences (MITHS). The MITHS summer program is available to sixteen students. For multiple years, a similar successful summer event aimed at Hispanic students, “Si, Se Puede,” has regularly had over fifty participants. A partnership was established in 2008 with the president of the Hispanic Dental Association and Latinos for Dental Careers for an additional summer enrichment program. Based on its success, the LLUSD admissions team created and has run a minority-focused Careers in Dentistry program since 2009. Additionally, URM alumni were solicited for help in mentoring and/or providing scholarship support to URM students in summer enrichment programs. This collaboration has been very helpful for these students. Some of these programs are multidisciplinary and, due to their association with other health recruitment programs, offer a wider target audience from which to draw for dentistry.

Enrichment and Outreach Programs

Post-Baccalaureate Program

Summer enrichment programs have been modestly effective in the school’s recruitment of URM students. These extended programs mentor high school and college students, help them develop study skills, and provide them with clinical shadowing opportunities, hands-on laboratory work, tours of the human anatomy laboratory and simulation center, panel discussions to better understand the intricacies of dental school from current students’ perspectives, and appropriate guidance concerning prerequisite


Loma Linda University is one of three universities in the Southern California Regional PostBaccalaureate Program, joining the University of Southern California and the University of California, Los Angeles in this regional program designed to provide knowledge, skills, and experiences to enhance URM student acceptance rates to dental schools. The three universities share their knowledge and make every effort to help the students become competitive dental school applicants. The eleven-month program is available to students from underrepresented and low-income backgrounds who have not been suc-

723

cessful in gaining admission to dental school. This program provides academic support, caring guidance, and clinical observation to academically and/ or economically disadvantaged students who have a strong commitment to a career in dentistry and a desire to serve in their communities. Post-baccalaureate program students attend a four-week summer program at each of the participating southern California dental schools. The curriculum at Loma Linda includes dental workshops, programs, lectures, and a dental anatomy course taught by the dean and a professor of restorative dentistry. Students are provided with practice tests that monitor their improvement, are tutored for the DAT, and enroll in a DAT prep course. Finally, these students receive mentoring and counseling about the dental school application process and participate in simulated interviews. At the conclusion of the summer program, these students return to their respective campuses and begin science courses to improve their preparation for dental school. Over a six-year period, twenty-four students have participated in the LLUSD Post-Baccalaureate Program, and seventeen were accepted to the school. Six students were not accepted, and one student who was accepted chose to attend another dental school. Of the seventeen accepted, six have graduated, and eleven are enrolled and on track for graduation. While the number of URM students has not yet reached desired levels in the School of Dentistry, substantial progress has been made as a result of the Pipeline program and especially the post-baccalaureate program. Each year the school has typically admitted two to five students who participated in the post-baccalaureate program, but the downturn in the economy and the expense of the program after the grant expired created a need to reduce the number of admitted post-baccalaureate students to two in 2011.

Cultural Competency Efforts During the Pipeline program, Loma Linda University School of Dentistry incorporated numerous changes in its curriculum so that cultural competency topics are included in each year. Cultural competence was addressed in eight courses (twenty-seven hours) in 2002, and currently fourteen courses (136 hours) contain components of cultural competence (Table 2) across all four years. Educational efforts

724

were expanded to address many aspects of diversity: ethnicity, age, gender, sexual orientation, disabilities, religious pluralism, class status, and social standing. A Spanish course for dentists is also available as an elective for all students. The dental school administration believes a student’s cultural competence is enhanced by immersion in another culture, achieved through its international service-learning rotations in which students spend one to two weeks in foreign countries providing pro bono dental care. In a typical year, 100 to 150 students travel to twenty to thirty countries and treat 4,000 to 5,000 patients. Providing dental service internationally has been part of LLUSD since the National Association of Seventh-Day Adventist Dentists conceptualized and created the school in 1953.19 During the 2009 Pipeline site visit by the national evaluation team, senior LLUSD administrators and faculty members expressed the belief that Pipeline cultural competency values were well embedded in the school’s mission. A faculty member noted, “The faculty in our clinic is a diverse population to begin with. There are times when there may be a situation of a language barrier, and we can invite [other faculty] to come over and work with that particular patient, and get the opportunity to observe how they communicate in their culture.”20 Since the 1980s, the school has used faculty members and dental students who are fluent in more than one language to assist patients whose primary language is not English. An annual survey of faculty, staff, and students assesses how many languages are spoken in the school. In the 2009–10 academic year, there were 315 employees who fluently spoke fifty-two languages, including American Sign Language. A translation service is also available by phone for those languages for which we do not have available translators. An annual translation orientation session is provided for these bilingual and multilingual employees. In 2009, Loma Linda University School of Dentistry conducted an assessment of patient languages in the clinic with a faculty and student survey. The survey found that bilingual or multilingual signs and health history forms were not an immediate need for the school’s clinic, as less than 3 percent of the patient population needed additional language assistance. The dean appointed a diversity task force comprised of faculty members to inform him and the diversity committee of implementation priorities and sustainability of the changes made during the Pipeline program.


Table 2. Cultural competency courses at Loma Linda University 2002 Courses with Cultural Competency Components

Current Courses with Cultural Competency Components

DNES 707: Personal Development DNES 794: Public Health Dentistry RELR 775: Art of Integrative Care RELR 715: Christian Dentist in the Community RELE 734: Christian Ethics for the Dentist DNES 851: Dentist and the Law RELR 749: Personal and Family Wholeness DNES 809: Practice Management

DNES 707: Personal Development DNES 794: Public Health Dentistry RELR 775: Art of Integrative Care RELR 715: Christian Dentist in the Community RELE 734: Christian Ethics for the Dentist DNES 851: Dentist and the Law RELR 749: Personal and Family Wholeness DNES 809: Practice Management SDCL 711: Clinic Orientation (OSCE) HIV and Dentistry: Clinic Training Program DNES 718: Communication Basics for the Dentist RELR 717: Diversity and the Christian Health Professional RELR 734: Christian Ethics for Dentists DNES 807: Practice Management

Community-Based Dental Education Nationally, 35 percent of the U.S. population does not have dental insurance, compared with 15 percent of Americans without medical insurance.13 In California, 39 percent of the population does not have dental insurance, while 13 percent of the population does not have medical insurance.13 These disparities increase the risk of morbidity in underserved populations. The Pipeline program aimed to reduce dental disparities by placing senior dental students in community clinics. All California dental schools participated in the Pipeline program, thus providing improvements in the delivery of dental care across California. To provide regular sustained care at six local community clinics, LLUSD students participate in service-learning rotations. In 2003, each student was required to complete six days of service. By the conclusion of the Pipeline program, dental students were completing a minimum of 120 hours of local service-learning prior to graduation; dental hygiene students were completing a minimum of seventy-five hours; and International Dentist Program students were completing at least sixty hours of service prior to graduation. Students are assigned a rotation that fits into their academic and clinic schedules. The rotations are distributed evenly per student, so each student rotates through each site. The students typically express appreciation for the additional experience of treating patients with sealants, prophys, fillings,


extractions, endodontic and periodontic procedures, and radiographs in a real-world setting. The southern California sites served include the Assistance League of Redlands, Baldy View Regional Occupation Program in Ontario, Lugonia Elementary School in Redlands, Mead Valley Community Complex in Perris, Victoria Elementary School in San Bernardino, and SACHS Dental Clinic in San Bernardino. In addition, Loma Linda students regularly provide pro bono dental care at multiple sites in surrounding communities on a volunteer basis. In 2011, 491 students volunteered to provide care at the following southern California sites: Compassion Clinic in San Bernardino, Calvary Presbyterian Homeless Clinic in Riverside, Urgent Care at the School of Dentistry in Loma Linda, Mead Valley Community Clinic in Perris, Share Ourselves Clinic in Costa Mesa, Give Kids a Smile events in San Bernardino and Helendale, Poplar Street Health Fair in Loma Linda, La Sierra Seventh-Day Adventist Health Fair at La Sierra College in Riverside, West-End Community Health Fair in Ontario, Colton Seventh-Day Adventist Church Health Fair in Colton, LLU School of Public Health Fair in Loma Linda, Clinic with a Heart in Loma Linda, and the Flying Doctors in Mecca. An average of 550 students participate annually in several additional volunteer activities such as urgent care dental facilities, workshop speakers, health fairs, hospital volunteering, participation in mission trips, student panels for recruitment activities, career days, food banks, continuing education courses, music ministry leadership, school tutors, elder care assistance, and blood donations.

725

As a private, nonprofit institution that depends on clinic income to provide approximately 46 percent of its budget, it is financially challenging for the school when students are not treating patients in the school clinic and providing pro bono care in community clinics for extended periods of time. However, because of their organization and clinical effectiveness coupled with a resolute commitment to service, a growing number of students now provide month-long dental care at off-campus sites. To enhance the community clinic-school partnerships, communication with the clinics was improved with regular phone calls, meetings, and enhanced reflection and procedural forms. Orientation sessions were established for each clinic where students provide care. Supervising faculty members are responsible for contacting students a week prior to their rotation through a clinic to discuss when and where the student will work, how long they will be in the clinic, and patient, school, and clinic expectations. Forms are consistently completed, and students do not receive credit if their forms are not completed and turned in. Students consistently acknowledge the value of working in community settings and the impact it has on improving their clinical skills, broadening their cultural awareness and communication, and enhancing their knowledge of practice management. These attitudes often appear in the written feedback students provide after their community experiences. “I learned I love helping and teaching underserved communities,” wrote one. “I learned how to use the public health method of documenting charts,” noted another. “I learned not to judge anyone by their appearance,” wrote another student, adding, “My patient looked rough, but was very sweet.” During the 2009 Pipeline evaluation team’s site visit, one student summarized the experience: “I think that [experience in community settings] is the biggest help because you see all these people are underprivileged, and interacting with them is a lot better than just being taught in the classroom because you are actually working with them and every student is required to attend a certain number of those blocks.”20 Loma Linda University School of Dentistry believes these activities, along with the many international service-learning trips, encourage future volunteerism and enhance students’ cultural competence. During the Pipeline program, a faculty member spoke with each graduating class about the importance of continuing their volunteer efforts after graduation. Each class responded, and the class of 2006 pledged

726

more than 650 collective hours of service each month to provide care to an underserved community. When the school’s alumni were surveyed in 2009, 209 respondents reported providing 15,751 hours of pro bono dental care.

Sustainability LLUSD’s Pipeline program provided many insights into increasing diversity in dentistry and dental education for all involved. Additionally, the program improved the delivery of oral health care to California’s underserved and disadvantaged populations. The school’s administration plans to remain focused on the sustainability of each segment of the program in the years to come. Enhancements have been made to the implementation of community-based dental education. Hiring an additional staff person to assign community clinic rotation blocks that fit into both student and clinic schedules has made the rotations more efficient. Additionally, required reflection papers have been added to the off-site clinic rotations as a result of the Pipeline program. These have helped students become more introspective about their experience and provide the faculty with insights into the benefits students receive. In these reflection papers, students have stated that their dental education and professionalism were enhanced as a result of CBDE experiences. Senior students are encouraged annually to work or volunteer in community clinics after graduation. The school also continues to seek ways to extend the benefits of the program. Graduates are encouraged to establish relationships with community dental clinics in the areas in which they practice in order to contribute to the dental safety net in California. The school’s collaborations with other California dental schools continue, as do its partnerships with community clinics—both sources of strength and future ideas for sustaining the program. Finally, the school’s success has been facilitated by support at all levels of leadership. In addition to their continuing support of community-based dental education, the dean of the school, the associate dean of admissions and service-learning, and the vice president all emphasize the need for continuing efforts to create more diverse classes with their annual charges to the Admissions Committee. In addition, the university president, Dr. Richard Hart, has held several meetings with representatives of all eight schools in the LLU complex, encouraging them to


collaborate on increasing diversity university-wide. All this support means that the school’s efforts to enroll more diverse classes, enhance the cultural competence of all students, and provide care to underserved populations were not merely a temporary commitment but will continue into the future.

REFERENCES

1. Pew Health Professions Commission. Critical challenges: revitalizing the health professions for the twenty-first century. San Francisco: Center for Health Professions, 1995. 2. In the nation’s compelling interest. An Institute of Medicine of Report. Washington, DC: National Academy Press, 2003. 3. American Dental Education Association. ADEA position paper: statement on the roles and responsibilities of academic dental institutions in improving the oral health status of all Americans. J Dent Educ 2011;75(7):988–95. 4. Sinkford JC, Valachovic RW, Harrison SG. Underrepresented minority dental school enrollment: continued vigilance required. J Dent Educ 2004;68(10):1112–8. 5. Sullivan LW. Missing persons: minorities in the health professions. Atlanta: Sullivan Commission on Diversity in the Healthcare Workforce, 2004. 6. Levison A. More blacks, Latinos are attending universities. Contra Costa Times, February 10, 2000. 7. Personal communication with Dr. David Brunson, Associate Director, Center for Equity and Diversity, American Dental Education Association, October 26, 2007. 8. Kennedy JE. Building on our accomplishments. J Am Dent Assoc 1999;130:1729–35. 9. Florida, California, and Texas to dominate future population growth, census bureau reports (press release). U.S. Census Bureau News, April 21, 2005. At: www.census. gov.Press-releasewww/releases/archives/population. Accessed: December 7, 2007.


10. Morris PJ, Freed JR, Nguyen A, Duperon DE, Freed BA, Dickmeyer J. Pediatric dentists’ participation in the California Medicaid program. Pediatr Dent 2004;26(1):79–86. 11. Pew Children’s Dental Campaign. The cost of delay: state dental policies fail one in five children. February 23, 2010. At: www.pewstates.org/research/reports/ the-cost-of-delay-85899378799. Accessed: May 16, 2011. 12. San Bernardino County, CA, demographics: 2010 census report estimate. At: http://quickfacts.census.gov/qfd/ states/06/06071.html. Accessed: May 16, 2011. 13. Dental insurance in California: scope, structure, and availability. Oakland: California Healthcare Foundation, September 2009. 14. Atchison KA, Thind A, Nakazono TT, Wong D, Gutierrez JJ, Carreon DC, Andersen RM. Community-based clinical dental education: effects of the pipeline program. J Dent Educ 2009;73(2 Suppl):S269–82. 15. Thind A, Atchison KA, Andersen RM, Nakazono TT, Gutierez JJ. Reforming dental education: faculty members’ perceptions on the continuation of pipeline program changes. J Dent Educ 2008;72(12):1472-80. 16. Mascarenhas AK, Freilich SR, Henshaw MM, Jones JA, Mann ML, Frankl SN. Evaluating externship programs: impact of program length on clinic productivity. J Dent Educ 2007;71(4):516–23. 17. Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students’ reflections on their community-based experiences: the use of critical incidents. J Dent Educ 2003;67(5):515– 23. 18. Holtzman JS, Seirawan H. Impact of communitybased oral health experiences on dental students’ attitudes towards caring for the underserved. J Dent Educ 2009;73(3):303–10. 19. The first 50 years, 1953–2003: service is our calling. Loma Linda, CA: Loma Linda University Press, 2004. 20. Crall JJ, Friedman JA, Atchison KA. The pipeline program at Loma Linda University School of Dentistry. J Dent Educ 2009;73(2 Suppl):S175–85.

727