Students’ Opinions About Treating Vulnerable Populations Immediately After Completing Community-Based Clinical Experiences Raymond A. Kuthy, D.D.S., M.P.H.; Keith E. Heller, D.D.S., Dr.P.H.; Katharine J. Riniker, D.D.S.; Michelle R. McQuistan, D.D.S., M.S.; Fang Qian, Ph.D. Abstract: The purpose of this study was to analyze students’ perceptions of comfort and anticipated willingness to treat selected special needs and traditionally underserved populations immediately upon completion of community-based clinical assignments. The sample consisted of University of Iowa senior dental students who completed a questionnaire that asked, in part, about student comfort with and future willingness to treat twelve vulnerable population groups. With student comfort and future willingness to treat each group as dependent variables, logistic models were developed to determine whether there were significant associations between dependent variables and gender, graduation year, and students’ prior experience with these groups. Regression models indicate students’ prior experience is most often associated with comfort in treating the associated population group. Likewise, experience and comfort add different dimensions to perceived future willingness to treat almost all of the twelve groups. Student gender, graduation year from dental school, and community assignments influence only a few of these targeted population groups. This study provides empirical evidence concerning students’ perceptions about comfort with various vulnerable populations after completing their extramural rotations. Students were more comfortable treating certain population groups as well as more willing to consider including these groups in their future practices. Dr. Kuthy is Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; Dr. Heller was Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry at the time of his death; Dr. Riniker practices clinical dentistry in Dubuque, Iowa, and worked with this research team while a dental student; Dr. McQuistan is Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; and Dr. Qian is Adjunct Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry. Direct correspondence to Dr. Raymond A. Kuthy, University of Iowa College of Dentistry, N337-2 DSB, Iowa City, IA 52242-1010; 319-335-7201 phone; 319-335-7187 fax;
[email protected]. No reprints will be available. This project was supported, in part, by NIH/NIDCR T32 DE14678 and Dows Student Research Award, University of Iowa College of Dentistry. Key words: attitude of health personnel, student comfort, extramural, willingness to treat, frail elderly, dental care for disabled Submitted for publication 12/7/06; accepted 2/22/07
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ommunity-based clinical experiences, sometimes referred to as extramural programs, help students to develop a broad understanding of the responsibilities they will have as dental professionals. Students observe and work with diverse social, cultural, and age groups and those who have medical, dental, personal, and other problems that are not often encountered within the predoctoral curriculum of U.S. dental schools. Moreover, these community-based experiences often expand students’ knowledge and technical capabilities, along with placing them in an environment that may present new and interesting challenges. Oftentimes, such facilities are either safety net health care providers (i.e., deliver a substantial level of care to the uninsured, Medicaid, or other vulnerable patients) or are dedicated to treating patients with specific needs (e.g., children and medically complex or mentally challenged patients). While community-
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based clinical experiences have been an integral part of the curriculum at many U.S. dental schools for a number of years,1 these experiences vary among institutions.2 There has been a resurgence of interest in these programs with the recent funding by the Robert Wood Johnson Foundation and the California Endowment of community-based education at fifteen U.S. dental schools that are participating in the dental pipeline project.3 Little data exist concerning students’ attitudes about community-based clinical education programs.4 Available data generally address either students’ overall satisfaction with a program5-7 or are specific to one group of individuals, such as those with mental retardation.8,9 While there is little information available about students’ perceptions subsequent to such external experiences, there is even less about the relationship between practitioners’ comfort with population groups and their future willingness
Journal of Dental Education ■ Volume 71, Number 5
to include these groups in their practices. Such information is important for community planning purposes, particularly when many of these groups are at higher risk for dental disease than the rest of the population. The purpose of this study was to analyze dental students’ perception of comfort in treating selected special needs groups immediately after completion of these community-based assignments. Moreover, the researchers explore whether gender, graduation year, experience with each population group, and students’ comfort in treating these populations influence students’ anticipated willingness to treat these population groups once they graduate.
Methods The University of Iowa initiated a communitybased clinical program in 1969.10 Since 1975, senior dental students have been required to participate in two consecutive, five-week community experiences. Students were appointed to each of two sites based on student preference (for either time during the academic year or site) and site availability. There were several in- and out-of-state affiliated programs including the dental school’s Special Care Program, which consists of an in-house, designated clinic where students primarily treat adults who are physically, cognitively, or mentally challenged, and the Geriatric Mobile Unit, which serves residents of several long-term care facilities in the surrounding community. Another site was Broadlawns Medical Center, a county public hospital in Des Moines, Iowa, that has a greater proportion of uninsured patients than elsewhere in the county. There were several other sites, such as community health clinics in Iowa and Colorado, a Veterans Affairs hospital, a children’s outpatient dental center, private practice preceptorships, Indian Health Service sites, and three overseas student exchange sites. While the preponderance of their time was spent providing clinical services, students were required to spend at least 15 percent of their time with other community experiences (e.g., group presentations, working with local social service employees). On the final day of their two experiences, senior dental students gather for an all-day exit seminar to discuss their activities of the previous ten weeks. These seminars occur quarterly throughout the academic year, with time set aside during the activity for students to complete a course evaluation and survey.
May 2007 ■ Journal of Dental Education
The findings presented here are for senior students who completed surveys over a thirteen-year period (i.e., graduated from 1992 through 2004). Besides questions pertaining to their comfort in treating and future willingness to treat (after graduation) twelve different vulnerable populations, the survey asked about students’ gender, race, and experience in dealing with these different populations. The twelve patient groups included (in the order that they appear on the questionnaire) the following: low income; frail elderly; homebound; medically complex; mentally compromised; homeless; drug users; other ethnic groups; Title XIX eligible (Medicaid); HIV+/ AIDS; jailed; and non-English speaking. Comfort was measured using a five-point Likert style scale (5=no problem; 4=OK; 3=some concern; 2=rather not; and 1=will not treat). Prior patient experience with the associated population group and anticipated willingness to treat patient groups beyond graduation were categorized dichotomously (Yes/No). Data were entered into an Excel spreadsheet and then converted to SAS (version 9) for analysis. This project was approved by the University of Iowa Institutional Review Board. Skewness of univariate frequency statistics determined that, for statistical analyses, comfort for each population group could be collapsed dichotomously into YES=comfortable (representing either no problem or OK) and NO=not completely comfortable (representing some concern, rather not, or will not treat). Approximately three-quarters of the students were assigned to Special Care (SC) and Broadlawns Medical Center (BMC) because of additional space availability and supervision at these sites, respectively. Thus, four community-based site combinations were created: Special Care and Broadlawns Medical Center (SC+BMC); SC and some other program besides BMC (SC+Other); BMC and some other program besides SC (BMC+Other); and two assignments other than SC and BMC (Other only). Bivariate analysis and logistic regression models were performed to determine important variables related to comfort in treating and future willingness to treat for each of the twelve vulnerable groups. This study assessed students’ gender, year of graduation, past experience with each group, and combinations of community-based student site assignments towards comfort in treating and future willingness to treat by initially analyzing differences between groups using either chi square statistic or the Cochran-Mantel-Haenszel test when there were
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more than two categories. If individual cell sizes were very small (i.e., less than 5), then the Fisher’s exact test was used for the bivariate analysis. All bivariate results that demonstrated statistical differences (p≤0.1) were included in the model building for the multiple logistic regression final models. If there were no statistically significant bivariate findings within that population group who met this criterion, then no regression model was developed. Variables were entered into models using stepwise regression, followed by forward and backward selection methods (p
