Dentists of the Future
The University of Washington reaches higher with new and expanded programs.
Any one of the changes happening at the University of Washington School of Dentistry over the past five years would be significant in its own right — the installation of a new dean, the complete overhaul of the curriculum and the clinic, the proposed expansion of the RIDE program in Spokane, and the opening of the state-of-the-art Center for Pediatric Dentistry. But to pack so many events into such a short time is spectacular for the school. Curmudgeons like Jeff Parrish take note: You may not have much to grouse about going forward. Now, not everything is perfect….yet. And we’re not even sure what parts of the RIDE expansion the Legislature will sign off on, but there is much to celebrate at the UWSoD these days. We met and talked with key players to get their take on the excitement.
The new curriculum rolled out this past June, and while they’re still ironing out a few kinks, everyone we spoke with focused on the promise it brings. The Regional Initiatives In Dental Education, or RIDE program, was founded in 2007 and graduated its first class in 2012. Today, because of the model’s success, the UW and WSDA are working with legislators to expand it nearly fourfold by the year 2019. The Center for Pediatric Dentistry was the brainchild of Dean Joel Berg, who, as then-chair of pediatric dentistry at the UWSoD and dental director for Children’s Hospital, had a vision for what the facility would bring to the community and the university as a whole. The irony is, the Center may have done its job too well. Because, while Berg was spot on about the need in the community, he couldn’t have known how the in-need population would swell or how valuable an asset the center would become, especially when it comes to the treatment of our most challenging young patients. Today, the center is straining under the burden of caring for the pediatric population, but they’re looking at ways to remedy that.
The Center for Pediatric Dentistry
When we first talked with Berg about this back in 2011, The Center had been open a year and was quickly approaching capacity in terms of the number of patients it was able to see. Initially, they hoped to see 120 patients a day - around 30,000 patients a year - at the state-of-the-art facility, and it seemed to be on track to meet that need. But along the way, the Center’s expertise at treating children with medically complex needs and social disorders like autism became known throughout the state. It has been a mixed blessing. The facility’s pro forma was based upon a different Medicaid reimbursement rate and a patient population comprised mostly of “otherwise healthy” patients – meaning their mouths aren’t healthy, but their bodies generally are. As Berg explained, “What is actually happening is that we are seeing disproportionate numbers of complex and special needs patients, and they take more time to treat, and the reimbursement is low. It has created a financial challenge for us to continue seeing that population, but we feel it is the most important part of the program. It’s a paradox. The greatest strength of the program is the care we provide to the state’s most challenging and unique patients, but it is financially unsustainable.”
Berg, along with the WSDA and state legislators, are looking at solutions, and they’re hopeful they will figure out a way to make it work. “I don’t want to paint a totally negative picture. We are committed to make it succeed,” said Berg. “We’re very proud of the Center. It has attracted some of the best candidates into our residency program, it’s a wonderful place for our faculty to practice, including myself, and, most importantly, the work we do helping children with complex issues is incredibly fulfilling. We are the one place they can go to, and the patients and their families love it.”
Social work solution
One surprising and crucial component to the success of the Center is the integration of social workers with the program. When the Center opened, it was the first of its kind to have a social worker on staff, and now other centers across the country have followed suit. Heather Marks, social worker for the Center, first heard of the idea when she was a temp at the UW studying for her MSW. “I realized that the population that I was studying at school was the same as our patient base at the Center,” she said. “Seventy-five to 80 percent of our patients are either Medicaid eligible or low income. I read a paper that had been done at the University of Buffalo where they started social work in the dental department for elderly patients, and I thought it could easily work in our patient population.”
Over coffee one morning, Marks pitched the idea to Berg. To her surprise, he jumped on it and agreed to make it happen. Today, Marks works with patients, staff, and faculty to ensure that every visit goes as smoothly as possible. With so many medically complex patients or those with other special needs, that’s not always an easy task. Charged with removing or easing barriers to care, Marks compares her work to that of all social workers. “The standard of care centers on the client’s needs. For our patient population, that mostly manifests as issues with transportation, insurance, language, and access, or paying for the care,” she explained.
There is also an educational component to Marks’ work, and not just for the families of the patients. It often includes educating faculty about the needs of the patients, too.
“I’m here to advocate for the patients, no matter what form that takes,” she said. That includes arranging rides to the facility, ferreting out state programs that pay for gas, providing toys and games to keep compromised or challenging patients happy and in check while in treatment, and arranging for interpreters for families with parents who don’t speak English. Marks’ position has had a far-reaching effect on the success of the Center. Berg said, “The social work has been incredibly important, so much so that we added a social work assistant. The interpretation piece is vital. I have many patients who don’t speak English even though their kids do. Unfortunately, I can’t negotiate the treatment plan with a 5- year-old. Everything about access involves a social worker because Medicaid patients have so many needs.”
The curriculum change at the UWSoD is generating the most water-cooler conversation these days. Innovative and intense, it has been reorganized around a collection of nine groupings called “threads” that encompass all the core competencies of general dentistry, plus areas such as “Ethics and Professionalism” and “Foundations of Human Health and Disease.” The new curriculum also includes a series of intensive third-year clerkship clinical rotations loosely based on similar programs elsewhere, most notably at the University of Iowa, where Berg studied. Iowa’s program is the most advanced clerkship program in the country, and they’ve worked out a lot of the bugs, according to Berg. But the UWSoD didn’t just copy and paste what Iowa had developed; they created a hybrid program using 30 percent culled from successful models like Iowa’s, the remainder grown here at the school, using input from a wide range of people. Sound familiar? It should. When we talked with Berg back in August of 2012, he said, “I want everybody involved, and I’m willing to look at anything — including going back to teams, a tiered structure, a medical model, or even a system like the one I had in Iowa. So, while I don’t know yet what the systems will look like in our clinics — we’ll have everybody take a good look at it, with the understanding that nothing is sacred.” To a great extent, and to his credit, he’s done exactly that. The program, a vertically integrated team approach, was designed with input by 25 faculty members and an additional mix of 30 staffers and students.
In addition, the basic science instruction in the first two years has shifted to a system with seven blocks of varying lengths. The first is called molecular and cellular basis of disease, which is about a seven-week block, and now students are in the second block, called invaders and defenders. The third is where the students study renal, pulmonary and cardiac systems, among others. During the blocks, rather than have basic science courses discretely, they’ll learn everything about that system – the gross anatomy, the physiology, etc.
But it wasn’t just the curriculum that changed. How it’s being taught is changing, too. Berg explained, “The new curriculum is taught in small group discussions with active learning. Some of the changes are harder for the faculty than the students, honestly. Changing the mode of teaching to active learning is something we’re not used to, but we know it is essential so we’re starting with this class.” Active learning flips the classroom – students get all the material at home, learn on their own through lectures and videos and other methods, then they come to class and do the homework with the help of a teacher so they have help if they stumble. Berg found that millennials prefer a different mode of learning. “The internet has changed everything, including the way people get information,” he said. “There is so much out there, and we want to take advantage of it and not require people to sit in a classroom for everything, so there is a big push toward active learning. It’s something we’re actively training ourselves on. It is new to a lot of us, too.”
The active model requires students to read a lot for each of the basic science classes, as much as two to three hours a day. They meet in groups of about 20, have some short group discussions and seminars with the medical students, and then break off into smaller groups and learn together. A group leader facilitates the active learning process. This year there were some additional challenges because changes at the medical school delayed delivery of the core materials dental students use. Berg and the faculty are hoping to remedy the issue going forward.
Changes to the clinic
Sweeping changes were made on the clinical side as well. Dr. John Sorensen of the UWSoD’s restorative department and Associate Dean for Clinics, a central figure in the curriculum change at the UW, was impressed with Berg’s approach to the change, one that utilized his extensive experience outside of academia. Berg introduced process analysis by having Danaher Business Systems come in and show faculty its technique for value stream mapping, which breaks down virtually any processes into individual steps. In November 2012, a group of 20 students, faculty, department chairs, and administrators assembled for two days and went through every step, from the first phone call through the screening process, treatment planning, the treatment, and then recall. The process included 36 steps, and each was then broken down to determine how long it took. They discovered a number of efficiencies with the existing system, and identified areas needing change. Their goal was to double or even triple the number of new patients they could bring in for evaluation. Additionally, only about 42 percent of patients continued on to treatment, so a new process called the Dental Admission Clinic was established for all new patients to go through. Comprised solely of faculty, the team screens patients in an hour, develops a problem list, determines a range of cost to the patient, and follows up by answering any questions the patient might have. The goal was to get to a yes or no answer regarding treatment and then assign the patient to the appropriate clinic. “We ran a pilot clinic a year ago in the fall and built it up, and now we have 10 sessions a week,” Sorensen explained. “Today, roughly 65 percent of patients continue on to treatment, our no-show rate has dropped, and patients feel like they’ve gotten a lot of attention because of the patient treatment coordinators and their follow-up. We’re processing about two and a half times more new patients than we were, and they are happier. However, if you talk to the faculty, we might not be as popular as we are with the patients.”
The numbers are impressive. The class of 2015 had 326 patient visits in the first eight weeks. Under the new program, that number has jumped to 2,850 visits. By all accounts, it has been arduous work, and the university has had to ask faculty to step up and do more teaching.
We spoke with Adrian Olson and Sohaib Soliman, both third-year students and part of the first wave to experience the new clinical program, to get their take on it. Though both expressed some reservations and concerns, they were generally quite positive about the new curriculum.
Olson said, “I have to say that I was pretty skeptical when I first heard about the changes, but now that we’re five months into it, I’ve been pleasantly surprised. It was a huge change, and it sounded like there were a lot of potential problems. We weren’t expecting it. There were so many unknowns, and it was just overwhelming… I think we were worried that we weren’t going to get enough experience, but we’ve really been getting a lot more than we thought.”
Olson likes the smaller groups, the clerkship tracks, and the extra help she gets in clinic. She likens the experience to a mentoring process, and says the program has enhanced her educational experience by focusing on two disciplines at a time. “It allows us to refine our technique and build on our previous day’s experiences. For example, if we didn’t like how a restoration turned out one day, we can discuss and implement changes the very next day, instead of waiting a week or more before doing our next filling, which might have happened under the previous curriculum. For example, since we’re only taking operative and endo at the same time currently, we have those every day, so we’re able to hone in on the details and figure things out. That is the biggest strength, that we’re totally immersed. I think previous classes could have a crown prep one day and then not have one again for two months, so they weren’t able to build on what they just learned.”
As class president, Soliman hears both pro and con opinions from faculty and students. While, like Olson, he’s quick to say he thinks the curriculum is an improvement over the past system, but he says staffing inadequacies have hurt the program. “To be honest it definitely has its rough patches, but overall despite not being perfect and not ironed out yet, it is better than what we had. We’re already seeing more patients than the class before us saw, and we’re performing more procedures. Some of us have had more procedures than people in spots before us ever had. I would say that definitely in certain parts of the clerkship we’re understaffed, and that can put a strain on things. Depending on the day, it can be tough to get the faculty to see our patients. The model hasn’t provided enough staff to sustain it. I know that Dr. Berg has been working with the WSDA to get more affiliate faculty to come in, and we have seen a little bit of an increase since the summer. But it’s still not perfect by any means.” Soliman also spoke about the large number of prophy patients they end up seeing, but acknowledges the role a cleaning plays in effective dentistry. “We all know that prophys are essential,” he said. “We’re just not equipped to handle the traffic.”
Both Soliman and Olson expressed concerns over patient continuity and redundancy. Olson said, “It’s kind of tough right now because patients are bounced around between students in different clerkships. They may come in for a treatment planning appointment, and then they get referred to a clerkship group, only to need care not provided by that group, which means we have to send them elsewhere.” The pair agree it’s tough on patients because they need the time to build rapport and trust, and the new system doesn’t necessarily allow for that.
Additionally, Olson describes problems with redundancies in treatment planning procedures that can add hours to a patient’s intake. “Before they have their treatment planning, they have a screening, which is pretty time consuming,” she explained. “It’s basically an appointment on its own. Then they have to schedule a treatment planning appointment, and then they’re referred to a clerkship. But when they get to the clerkship, we basically do another treatment plan for them, and sometimes it coincides with the previous treatment plan, and sometimes it doesn’t, which can be frustrating for the patient.” In her opinion, it’s frustrating for the students and the faculty, too, because if they’re going to provide treatment to a patient, they have to concur with the treatment plan, and they don’t always have access to the instructors who might have made the previous plan. “You can’t consult with the team who made the initial treatment, you’re just going off of what you have in the computer. I think that is still being streamlined,” she said, hopefully.
Sorensen conceded that there can be issues, but explained, “It might be a disadvantage for the patient because they have to see more than one student depending on the procedure, but on the other hand the patients move much more quickly through the treatment, as opposed to being spread out over a year or longer. We still have individual encounters. For instance, during oral diagnosis and treatment planning, they’re probably with a patient for nearly two hours. The other thing that we’re doing is that we have a patient advocacy program where the students are given a cadre of 15 to 20 patients who they help manage. They may not even be treating the patients, but they are managing them, making sure they’re not falling through the cracks, and helping to deal with any issues that arise. It allows us to offer more of that patient interaction experience.”
More school for their buck?
In reference to the longer school year (the program adds nearly seven weeks to the school calendar), Sorensen said, “As you can imagine, this process has been challenging at times for both faculty and students. But let’s look at the class of 2016 in the regular program and what they did in the first eight weeks of the fall quarter and compare that to what the class of 2017 saw in the first eight weeks of the summer. The new clerkship class has seen about 400 more patients than the class of 2016 had seen by this November.” Sorensen likened the program to a mini residency in its intensity, and said, “This new class of students with the new curriculum are probably about six months ahead of their predecessors, and the students have been generally happy with the clinical experience, and we’re extremely happy with how we’ve improved the educational program and the number of patient visits.”
As for the longer school year, Berg is polite, but said, “We changed the timing for the current third-year students. They lost about seven weeks of what would have been vacation time. I wouldn’t call it pushback, but we got a couple of complaints and grimaces. It was a vocal minority, but I remember when we announced it to them a year and a half ago, and there were a couple who were outspoken. My response was to be a listener and say, ‘You’ll never get a chance like you have at UW to learn what you have to learn.’ I don’t know how to put it into four years, and we’re giving you more learning with the program, more education, and we’re not charging you more. I think the vast majority of the students were fine and accepted it. We didn’t get any pushback from the new people because they understand that this is what is expected in the program.”
Olson and Soliman generally agree, with caveats. For both, it’s not about free time to lay in the sun. Olson explained, “It’s a conflict, to be honest. It’s no secret that dental school students work hard and only having four weeks off in a year does pose challenges. For instance, if we want to pursue any extracurricular or enrichment opportunities that require time off, we’re choosing between that and time with family and friends. That’s tough. But it’s conflicting because when I’m in school, I often feel like there is not enough time to learn everything that I want to. I’m in the prosthodontics clerkship now, and we have to do a lot of our own lab work, and we often feel like we don’t have enough time to complete all of our cases. Prosthodontics requires a lot of time to fabricate dentures and process, and we wish we had more time.… but we also want time off.”
For Soliman, who has to juggle the busy schedule along with the demands of being an ASDA rep and class president, the tight schedule leaves him little time for additional learning opportunities, and that may make it harder for him to land the oral surgery residency he wants.
Changing on the fly
So how will the school address problems and inadequacies they discover in the new curriculum as they develop? It depends on the problem, according to Berg and Sorensen. “We’re looking at changes we can make on the fly, but there are so many interlocking pieces that, even though it might seem like it would be easiest to change something as we encounter it, it is sometimes better to wait and make changes at one time,” explained Berg. “As we see operational or clinical issues, we can change those on the fly. But content, curricular issues, and issues with clerkships are things that we might change all at once. If you expend too much effort trying to make changes on the fly, you don’t pick up how things interact with one another. That’s the life of a dean, though. People are always coming forth with great ideas – students, faculty, and staff. And it’s not that the ideas aren’t good individually, but you have to figure out how they all fit together. That’s why it’s so important to get large groups together to do strategic planning, and process improvement that involves a larger team.”
Sorensen added, “On the fly we’re developing metrics and monitoring systems so that we can track data on a weekly basis. We recently celebrated the one-year existence of the Dental Admissions Clinic, and we just scheduled a half-day value stream mapping session with about 14 people to see what is slowing us down, what we can improve, what we’re doing right, and so on. We want to do a continuous process improvement, so we’re applying that diligently. We monitor the development of the third- and fourth-year students very closely, and we try and fill in where they have needs or remediation.”
Up next year
When the current third-year students transition next year, they’ll be taking on an entirely new clinical setting where they are working in a typical practice environment, albeit on a larger scale. Sorensen explained, “Then when they go into their fourth year GP, they will be doing everything from A to Z. That’s the plan and the vision of the dean. They will do the workup, diagnosis, treatment planning, and then do all endo, perio, restorative work, just as they would in a general practice clinic. For all intents and purposes, they will be practicing general dentistry.” The challenge, of course, is staffing that clinic, getting everyone on the same page, and standardizing and calibrating each of the full-time faculty so that everyone teaches the material the same way. In order to accomplish that, the dental school is planning a boot camp that will provide them with about 40 hours of continuing education. “It’s very similar to privileging in a hospital where you have to be certified to perform a procedure. It’s critical to have all of the faculty on the same page, even though we know there will be minor differences. If we can follow the 80 percent rule and get all of the faculty following nearly the same philosophy, standard, and background in at least 80 percent of procedures, we’ll have better students because of it.”
Expanding the RIDE program in Spokane
The RIDE, or Regional Initiatives In Dental Education program was funded by the Legislature in 2007 and graduated its first class in 2012. In its current configuration, eight students attend their first year of dental school at the Riverpoint campus of Eastern Washington University in Spokane and Washington State University in Pullman. The first-year curriculum is equivalent to the UWSoD’s and is taught by faculty from UWSoD, EWU, and WSU. The program leverages distance learning where it works smoothly, and otherwise uses live teaching. The first year includes a four-week community-based rotation in a dental clinic in a rural and underserved community. RIDE students currently spend the second and third years of dental school at the UWSoD Seattle campus. According to Dr. Mary Smith, clinical director for the program, under the proposed expansion, the program would add eight students in the first phase, followed by another eight in 2019, and have an ultimate capacity of 30.
Rather than going to Seattle for the second year, students would stay in Spokane, provided the state provides the funding to construct a facility to house the students. Their plan is to build a dental lab big enough for 40 students, which is the size of EWU’s hygiene class. Smith explained, “The expansion of the RIDE program is both an expansion in time – they can spend more of the four years in Spokane — as well as an expansion in the number of students. The dental hygiene school at EWU is one of the top programs in the country, and they currently do not have a simulation space, so if they’re using typodonts they have them strapped into dental chairs in their clinic, which is clearly not ideal. If we can build a simulation space that is big enough for them to share, they’ll be able to use our simulation space, and we’ll be able to use their clinical space. Part of the plan is to bring some of the RIDE students back to Spokane in their fourth year to do patient care.”
The program seeks to create what it calls the “super generalist.” To produce such clinicians, students get extra training in oral surgery, operative dentistry, pediatric dentistry, and perio so they can perform more difficult procedures, but also so they can recognize when a procedure is better handled by a specialist. RIDE director Dr. Frank Roberts said, “They need extra training because it’s not as simple to refer someone in some of these small rural communities, and that’s our primary goal — to get dentists into rural and underserved areas. The secondary goal is to build leaders in rural and underserved dentistry. So we’re really not looking for students to graduate and go to work in underserved communities, and then move on. We want them to run community health centers, to become leaders, and help shape policy for the state.”
RIDE classes teach students about how community health clinics work, how public health works, and how rural dentistry leadership works. “We want them to spend their careers in these areas,” said Roberts. “We recruit specifically for these positions, and we’ve been successful. The majority of the students we see in the program are from those areas, so they know the community, the lifestyle, the pace, and it appeals to them. We want people who are predisposed to being happy in the environment. We know it is extra work, and we want people who are comfortable with that.”
Roberts isn’t surprised at all by the success of RIDE students. “The RIDE program is not a back door into dental school,” he said. “We view our students as an elite group who are able to function more independently and want that. We track every student who graduates and what they do. In fact, we’re transitioning to doing that for the whole school, and we’re serving as a model for that. We’ve had four graduating classes, and 77 percent have stayed in rural and underserved communities. I know that sounds good, but the national average is about 4 percent, so you can see how dedicated our people are. It’s a new program, and some have stayed in those settings because there are incentives with student loan repayment if they stay, so it will be interesting to see what the long-term percentages are. We’ll look at five- and 10-year increments.”
Smith and Roberts are trying to figure out what their role is in helping the graduates become as happy and successful as possible serving in rural and underserved areas. “We have hundreds of combined years in training students, but not as much experience with what to do with alumni development related to career path training,” said Roberts. “We’re looking at what we can do to make them feel connected to job opportunities in the region, and also what they need to be successful.”
It’s an exciting time at the University of Washington School of Dentistry. At the WSDA, we’re proud to play a role in the continued excellence of the school, and excited to see how these programs and expansions serve both the professional community and the people of the state.