Reforming Dental Education: Faculty Members’ Perceptions on the Continuation of Pipeline Program Changes Amardeep Thind, M.D., Ph.D.; Kathryn A. Atchison, D.D.S., M.P.H.; Ronald M. Andersen, Ph.D.; Terry T. Nakazono, M.A.; John J. Gutierrez, B.A. Abstract: In 2002–03 the Robert Wood Johnson Foundation (RWJF) established the Pipeline, Profession, and Practice: Community-Based Dental Education program to change dental education in the United States. In partnership with The California Endowment, the RWJF awarded grants to fifteen U.S. dental schools that would support them in efforts to recruit more underrepresented minority/low-income (URM/LI) students, add cultural competence training, and increase extramural rotations to sixty days. As the program evaluator, the University of California, Los Angeles, School of Public Health (UCLA-SPH) conducted a survey of dental faculty in 2006 related to the goals of the Pipeline program. In this article, we report faculty perceptions pertaining to the extramural rotations and URM/LI recruitment. The survey was conducted in fourteen U.S. dental schools that received Pipeline grants and had an overall response rate of 60 percent (n=1,027) from the 1,713 faculty members who received the survey. A majority (57 percent) of faculty members strongly agreed that extramural rotations should continue as an integral part of students’ education; 51 percent felt the same about the continuation of URM/LI recruitment programs. Multivariate logistic regression analyses revealed that faculty type, perception of extramural rotations being a positive experience, increased student productivity, and school culture were significant determinants of support for continuation of the extramural rotation programs. Determinants of support for continuation of the URM/LI recruitment programs were faculty type, perception of URM/LI recruitment effectiveness, perception of students from diverse backgrounds improving educational experience, and having a school mission statement that supports URM/LI recruitment. Pipeline schools should ensure that their extramural faculty remain key players in the Pipeline programs, widely publicize the programs’ successes, and develop a service-oriented culture in order to build and sustain faculty perceptions that these programs should continue as integral parts of the schools’ educational mission. Dr. Thind is Canada Research Chair in Health Services Research and Associate Professor, Department of Epidemiology and Biostatistics, Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario; Dr. Atchison is Professor, School of Dentistry, University of California, Los Angeles; Dr. Andersen is Professor, Department of Health Services, School of Public Health, University of California, Los Angeles; Mr. Nakazono is Programmer Analyst, Department of Health Services, School of Public Health, University of California, Los Angeles; and Mr. Gutierrez is Project Manager, Dental Pipeline Evaluation, Department of Health Services, School of Public Health, University of California, Los Angeles. Direct correspondence and requests for reprints to Dr. Amardeep Thind, Center for Studies in Family Medicine, University of Western Ontario, 245-100 Collip Circle, London, Ontario N6G 4X8, Canada; 519-858-5028 phone; 519-858-5029 fax;
[email protected]. Key words: pipeline program, extramural rotations, URM/LI recruitment, faculty perceptions Submitted for publication 5/2/08; accepted 9/8/08
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n 2002–03 the Robert Wood Johnson Foundation (RWJF) launched the Pipeline, Profession, and Practice: Community-Based Dental Education program with the aim of changing dental education in the United States.1 Eleven dental schools were competitively selected to receive five-year grants that would help them to recruit more underrepresented minority and low-income (URM/LI) students, introduce additional cultural competence training in their curricula, and increase students’ extramural rotations in community sites to sixty days. A year later, The California Endowment (TCE) funded four additional California dental schools (the University of California, San Francisco, was originally funded by the RWJF) to undertake similar curricular changes.
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The focus on increasing URM/LI student recruitment and supporting curricular change was based on well-documented evidence of need. The demographic character of the United States is changing, with nonwhites becoming an ever-larger proportion of the population.2 However, this shift is not mirrored in either the student body entering dental schools or in the dental provider community.3 More than a decade ago, a report from the Institute of Medicine called for a dental workforce that is representative of the nation’s ethnic makeup.4 Although Hispanics and African Americans each comprise approximately 10 percent of the U.S. population, each group accounts for only 3.3 percent of dentists.5 This disparity has potential negative consequences for minorities, as evidence suggests that they experience greater need
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for, and encounter greater barriers to accessing, oral health care.6-8 Eliminating this disparity would improve access to care since the literature suggests that minority dentists are a significant source of care for minority patients.9 Extramural rotations, another important part of the Pipeline program, are a mechanism for exposing dental students to underserved populations they would not encounter within the main school clinics.10,11 Research evidence suggests that senior students who have spent time in such community clinic rotations were significantly more likely to be confident and prepared to enter the dental profession.12 By the end of the five-year Pipeline grant period, all the schools involved had instituted programs that made significant progress in meeting the three goals of the Pipeline program.13,14 The University of California, Los Angeles (UCLA) School of Public Health was chosen as the national evaluator of the Pipeline program, as previously reported in this journal,15 and, as part of its mandate, conducted a survey of all faculty members of the participating schools in 2006. Among other questions, the survey inquired about faculty members’ perceptions of the changes made at their respective schools as part of the Pipeline program. In this article, we report on the perceptions of faculty at Pipeline dental schools pertaining to the extramural rotations and URM/LI student recruitment.
Materials and Methods Our data source was the 2006 Pipeline faculty survey, in which fourteen out of the fifteen Pipeline schools participated. The goal of the survey instrument was to capture faculty perceptions related to the Pipeline program. The survey was administered to all dental school faculty members in these categories: those holding 40 percent or greater time appointments, basic science course chairs, and community dentists who had supervised one or more students in the past two years. Questions focused on extramural rotations, overall quality of care, recruitment programs and their effectiveness, and barriers to sustainability. Out of 1,713 surveys administered, 1,027 were returned, which is a 60 percent response rate. Two dependent variables were constructed. The survey asked faculty members to indicate their agreement/disagreement with the following statements: “extramural clinical rotations should continue as an integral part of the students’ clinical education” and
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“recruitment of URM/LI students should continue as an integral part of the dental school’s mission.” Responses were on a scale from 1 (strongly disagree) to 4 (strongly agree). Due to the skewed nature of the responses, we dichotomized the variables into “strongly agree” (category 4) and “not strongly agree” (categories 1, 2, and 3). For independent variables, we posited that faculty members’ perceptions regarding the continuation of the extramural rotations were a function of individual and contextual level factors. Individual level factors were the following: 1) gender; 2) race/ ethnicity (URM, Asian/Pacific Islander, white, prefer not to specify); 3) faculty type (full-time intramural instructor, part-time intramural instructor, extramural instructor); 4) perception whether extramural rotations are a positive or negative experiences in a student’s education (coded as very positive, not very positive, don’t know); 5) productivity of students in extramural rotations (much more, more/less, and don’t know); and 6) whether the respondent feels that the school has a culture that emphasizes serving the community and promoting access to dental care (strongly agree/agree, neutral/disagree/strongly disagree). Regarding the fourth factor, response categories to the question “Are extramural clinical rotations in community settings positive or negative experiences in students’ education?” were very negative, negative, neutral, positive, very positive, and don’t know/not familiar with the program. Due to the skewed nature of the responses—56 percent (n=502) replied “very positive” and 36 percent (n=325) replied “positive”—we decided to trichotomize the responses to very positive, not very positive (including the response categories positive, neutral, negative, and very negative), and don’t know. Regarding the fifth factor, response categories to the question “Are senior students more or less clinically productive in extramural clinical rotations than in the main school clinics?” were much less, less, same, more, much more, and don’t know/not familiar with the program. Due to the skewed nature of the responses—29 percent (n=220) replied “much more” and 52 percent (n=390) replied “more”—we decided to trichotomize the responses to much more, more/less (including the response categories more, same, less, and much less), and don’t know. Contextual factors were created using a variety of data sources. The type of school (publicly funded or privately funded) was based on data from the American Dental Association (ADA). Pipeline status (RWJF or TCE awardee) was derived from the
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National Program Office that coordinates the Pipeline program. Using data available on each school’s website, a variable capturing whether the school has a mission statement committing it to serve the URM population (yes, no) was created. The percentage of the population below 200 percent of the federal poverty level in the county where the school is located was based on the 2000 U.S. census. Further details regarding the construction of these variables are available elsewhere.16 Individual level factors for the model predicting perceptions regarding the continuation of increased URM/LI recruitment were gender, race/ethnicity, faculty type (coded as above), effectiveness of the URM/LI recruitment program (good/excellent, poor/ fair, don’t know), and the perception that having students from diverse backgrounds improves the educational experience (strongly agree, not strongly agree, don’t know). Contextual factors were type of school and Pipeline status (both coded as above), a binary variable capturing whether the school has a mission statement committing itself to URM/LI recruitment, percent URM population in the county, percent URM faculty in the school, and percent URM students in the school. These contextual variables were created using the data sources enumerated above. Data analyses were carried out using Stata 10.2.17 The unit of analysis was an individual faculty member (n=1,027). Missing data were not a problem except for two variables: gender and race/ethnicity. Nonrespondents to both these questions were coded as “prefer not to specify” and were included in the analyses: 13.8 percent (n=135) preferred not to specify their gender, while 17.4 percent (n=170) preferred not to specify their race/ethnicity. Unadjusted odds ratios were calculated to evaluate the relationship between the dependent and independent variables. Adjusted odds ratios were obtained by performing logistic regression analyses, which included all the independent variables in the model. Overall goodness of fit of the logistic regression model was assessed using the Hosmer-Lemeshow test.
Results In our sample, 57 percent of the respondents strongly agreed that extramural rotations should continue as an integral part of the students’ clinical education; only a slight majority (51 percent) had the same sentiment towards the continuation of URM/LI
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recruitment (Table 1). Our sample was predominantly male (62 percent) and white (62 percent); full-time intramural instructors accounted for 60 percent of all respondents. Nearly half of the total respondents felt that extramural rotations were very positive experiences in students’ education, but only a fifth (22 percent) felt that students were much more productive during the rotations. A majority agreed that their school had a culture emphasizing community service and promoting access and that having students from different backgrounds improved the educational experience. While 43 percent felt that the effectiveness of their school’s URM/LI recruitment program was good/excellent, nearly a third (32 percent) responded that they didn’t know its effectiveness. A large majority of schools did not have a mission statement espousing commitment to serve the URM population (77 percent) or to URM/LI recruitment (83 percent). The counties where the dental schools were located had a mean number of four federally qualified health centers (FQHC), and counties represented by the respondents had nearly a third of the population below 200 percent of the Federal Poverty Level (FPL). The mean percentage of URM dental students and URM faculty in the fourteen schools was 14 percent and 12 percent, respectively.
Extramural Rotations Table 2 presents the unadjusted and adjusted odds ratios for the association between the two dependent variables and individual and contextual independent variables. Unadjusted analyses show that male faculty members and those who did not specify their gender were less likely than female faculty members to strongly agree with the statement that extramural rotations should continue as an integral part of the students’ education. Asian/Pacific Islander faculty and those who did not specify their race/ethnicity were also less likely than URM faculty to agree with the statement, while extramural faculty members were more likely than full-time intramural instructors to strongly agree with the statement. Faculty perceptions that student productivity was higher and extramural rotations were a positive experience were both strongly associated with the perception that extramural rotations should continue as an integral component of the curriculum, as was a perception that the school has a culture emphasizing community service and promoting access. None of the contextual variables (type of school, Pipeline status, number of
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Table 1. Descriptive characteristics of the faculty members surveyed and their perceptions regarding extramural rotations and URM/LI recruitment, by number and percentage of total responses Extramural rotations should continue as integral part of the student’s clinical education Not strongly agree 385 (43.0%) Strongly agree 511 (57.0%)
Recruitment of URM/LI students should continue as integral part of the dental school’s mission Not strongly agree 446 (48.6%) Strongly agree 471 (51.4%)
INDIVIDUAL FACTORS Gender Prefer not to specify Male Female
135 (13.8%) 606 (61.8%) 239 (24.4%)
CONTEXTUAL FACTORS Type of school Public Private
608 (59.2%) 419 (40.8%)
Race/ethnicity URM Asian/Pacific Islander White Prefer not to specify
111 (11.3%) 93 (9.5%) 606 (61.8%) 170 (17.4%)
Pipeline status RWJF school TCE school
668 (65.0%) 359 (35.0%)
Faculty type Full-time intramural instructor Part-time intramural instructor Extramural instructor
594 (60.1%) 184 (18.6%) 211 (21.3%)
Extramural rotations are positive/negative experiences in students’ education Not very positive 398 (39.1%) Very positive 502 (49.4%) Don’t know 117 (11.5%) Productivity of students in extramural rotations Less/more 529 (52.2%) Much more 220 (21.7%) Don’t know 265 (26.1%)
School has mission statement that commits to serve URM population No 789 (76.8%) Yes 238 (23.2%) School has mission statement that commits to recruitment of URM/LIs No 856 (83.4%) Yes 171 (16.6%) Number of FQHCs in county
4.1*
Percent population in county
