June 10, 2013
Dental schools across the country do a remarkable job of educating the next generation of dentists, but as sound as those programs are, recent graduates could all benefit from additional practice, mentoring, and education. Cuts to Medicaid have diminished patient loads in the university setting, forcing students to scramble to complete clinic requirements, often performing procedures on extracted teeth rather than live patients. It’s unclear at this point when state legislatures will revisit Medicaid funding. General Practice Residencies (GPR) and their counterparts, Advanced Education in General Dentistry (AEGD), could hold the key to providing the additional education, while at the same time increasing access to underserved patient populations in the state.
A combination of both clinical care and didactic education, residency programs provide more advanced training than universities can offer, even in elective course study. In the past five years, the number of residency positions in the state has swelled to 24, with seven more positions on the way this summer. Each program lasts a year, from July to June, using anywhere from two to eight recent graduates from across the country — with some international students from as far away as India. The residencies vary in size, location, and specialty; ranging from hospital-based programs in Seattle, to those in community health centers in rural towns. They all expand the dental safety net, utilizing dentists who can perform the full scope of procedures, while teaching them advanced skills, increasing their speed and confidence, and leaving them better prepared for the practice of dentistry.
The WSDA News recently reached out to ten dental professionals who know the value of residencies first hand — from attending dentists and dental directors Drs. Amy Winston, Bart Johnson, Noah Letwin and Mark Koday, to current residents from across the state — Drs. Danny Trembleayy, Jennifer Westcott, Amanda Spivey, Taylor Berry, Peter Dang and Kim Siler. All of the residents we spoke with called the experience invaluable — and noted that time spent in a resident program could only enhance the abilities and confidence of new dentists. Each, too, professed a commitment to continuing to help the underserved, no matter where their futures take them. At the WSDA, we see the value in this model as well, and are actively working on a capital budget proposal to help community health centers in Toppenish, Othello, and Walla Walla expand physical clinic capacity in order to increase the number of dental residency positions available in rural Washington.
Choosing a residency
Why does a new graduate make the choice between going directly from dental school into practice, versus taking another year to explore a residency or specialty? For the people we spoke with there was no question that something more was needed — no matter how robust their dental education was. “People don’t know what they don’t know,” said Dr. Amy Winston, of Seattle Special Care Dentistry, who along with Dr. Bart Johnson runs the Swedish GPR, one of the state’s most intense residency programs, where they work primarily with challenging, medically-complex patients. “They get out of dental school and they think they’re ready, but really, without doing a residency there’s so much they haven’t seen or done that they inadvertently limit themselves.”
Dr. Danny Tremblay was in one of the first graduating classes at UWSoD to be affected by the cuts in Medicaid. He took a residency in Yakima at the Yakima Valley Farm Workers clinic under Dr. Mark Koday because, while he says the UW did a tremendous job of training him to be a competent clinician, he felt he needed more experience — not only get faster, but to develop a routine and an understanding of how long a procedure would take. And while Tremblay was appreciative of the didactic offerings of his residency, he completed even more CDE on his own, attending the ADA Annual Session, the PNDC, and the American Academy of Cosmetic Dentistry annual session.
Dr. Amanda Spivey, who is finishing up her year in Seattle over at the Swedish residency program with Drs. Winston, Johnson and Letwin, originally thought about going into a specialty, but didn’t know what she wanted to specialize in. Her mentor dentists from school steered her in the direction of a residency instead. Spivey knew she wanted to continue her education to expand her knowledge of surgery and medicine, and so she chose a GPR over an AEGD, because the focus is more medically-based. “I really see no downside to a person doing a year of residency,” she said, “Had I gone directly into a dental practice out of dental school, my potential for learning about these advanced dental procedures and complex medical patients would have been limited to CDE courses; this year I have been able to learn about them didactically, while also being able to treat these patients clinically. It has been a great year and has given me an education base that will allow me to grow more as a practitioner in the future.”
Over in Spokane, Dr. Peter Dang took an AEGD residency because, “I simply did not feel ready to take on and be responsible for my own clientele right out of dental school. I needed more time — not only to hone my skills, but to find my voice, and develop my philosophy of dentistry. I did not do enough in school to be able to determine who I was, or what I was willing or able to do. At NYU, there were many more opportunities for hospital-based GPRs because of the urban setting, but I thought an AEGD matched my needs more closely.” The program exceeded his expectations, and he feels the AEGD is the way to go — as long as a resident isn’t planning on specializing in oral surgery later — comparing it to an accelerated first year of private practice. “Sure,” he admits, “I don’t know how to intubate a patient, or place an IV, as I would if I had done a GPR, but I’ve done a tremendous amount of dentistry, regardless.”
Dr. Kim Siler is also in the Spokane residency, and always knew she’d invest the time in some sort of residency program, but settled on an AEGD because she knew she would likely land in a general practice upon graduation. “If I could have found a dentist willing to mentor me through the transition phase, I might have done that instead, but it’s hard to find somebody like that. In a residency, they’re not so concerned about taking longer to do a composite, as long as you continue to improve. This program allowed me to improve at my own pace, and that fit my style of learning the best.” And, while having a dentist mentor might sound good, it’s not without some serious limitations, as Johnson points out, saying “The power of residencies is that they have multiple attendings, hours and hours of formal seminars, educational structure, and accreditation standards to meet —none of which is available in a apprenticeship in a private practice.”
Dr. Noah Letwin has a unique perspective — three years ago he was a resident at the Swedish residency, today he is an attending dentist for the group. When he arrived for his residency he was overwhelmed, likening the flow of information to “trying to sip water from a fire hydrant,” while adding, “I don’t think there’s any substitute for the kind of hands-on experience you get in a residency. You may have been exposed to some of this in dental school, but once you’ve seen a sufficient number of patients in a residency program, your understanding of complex problems — be it heart disease, renal failure, or liver disease — becomes much more cemented. The residency took my skills to the next level, and allowed me to treat a much broader patient population than I would have been able to with just a dental school education.”
Letwin says that because of his year in the residency, he has a better understanding of dental complexities, is able to perform sedation and work with an anesthesiologist, and understands hospitals. Moreover, once he finished his residency he knew that he would be able to treat anyone.
Dr. Jennifer Wescott, another resident at Swedish, concurs with Letwin, and even though when she returns to private practice in June she’s not likely to have the kind of patient population she’s working with now, she plans on growing it. She’ll be returning to Florida to practice with her father, who for 30 years has run a successful “bread-and-butter” practice. Westcott found the Swedish residency on the internet, and felt its appeal immediately, saying, “This program is unique because it is based out of a private practice rather than a university or hospital, so it felt more applicable to life after the residency. I was drawn to the emphasis on procedures that I wanted more training in — particularly IV sedation and treating medically-complex patients. Even if I’m overtraining in complex procedures now, I know that when I’m treating run-of-the-mill patients I’ll feel confident to handle any issue that arises. Also, I think that patients with complex issues have trouble finding care, and this program provides me the tools and information to treat them competently once I graduate, which I fully plan to do.” Life after residency should have an interesting dynamic for Westcott, who goes to her father’s practice as the expert on procedures like placing implants, extracting third molars, IV sedation and treating medically-complex patients.
Adding value to their practice
For the attending dentists, having residents adds much to their practice — from increasing their productivity by having more licensed dentists on board, to the influx of enthusiasm and new dental techniques that residents bring with them. Having their salaries paid for by the federal government makes the program even more enticing, especially at Community Health Centers, which lost most state funding two years ago. There, having residents not only helps with their bottom line, says Koday, “It keeps us challenged. For me, and many of the other dentists, it reminds us of the excitement we felt when we first graduated from dental school, we’re always pumping them for information, and they are constantly pumping us for information. Being able to do a procedure and being able to teach how to do a procedure are two very different things — so it forces you to go back to the books. You have an obligation, and you can’t give residents incorrect information, or information that isn’t current. It renews you — they’re a fun group to work with. The other part of it is — and I think I can speak for all dentists — the dental profession has been good to us, and this is a way of giving back to the profession. By working with residents you’re ensuring that they have a good start to their career.” Johnson, agrees, saying “We give them a skill set that they cannot get in dental school, which will have a huge downstream effect over the course of their careers. It’s fun, exciting and brings a lot of energy into the practice, which keeps us young. It helps us tremendously to treat the needs of the population we’re trying to reach.” Plus, Johnson says, he just loves teaching — “I have been teaching residents for all of my career and I just love the residency model – I love to teach, I love the idea, I love everything about it. We’re turning out three (soon to be four) highly qualified dentists a year, which gives them a jump-start on their career.” Winston adds, “Having residents allows us to see more patients and increase our volume significantly. Additionally, they bring positive, youthful energy to the place that is really exciting. We get to learn what they’re being taught in dental school – we’ve all been out a certain number of years, and it’s really nice to keep up on what’s being taught currently. We are allowed to do a lot more charity care because of the residents — it enables us to provide care to underfunded patients that we wouldn’t be able to do otherwise. Plus, we’ve been able to participate in some amazing things in the community, like the NW Kidney Center Program, and the SCSC Clinic over at Swedish. The residents provide exponentially more opportunities to our practice.”
Even with federal funding paying their salaries, having residents on staff is a labor of love, according to Johnson, who relates, “While we don’t pay their salaries, we pay with our time, our energy and our expertise. The biggest problem with business people who want to set up new residencies is that they often think they can start one up, get free labor and not have to do anything more. Nothing could be further from the truth!”
Much has been said in the past decade about midlevel providers and access to care, but for the most part the real culprit is not access, it’s funding. Until the economy rights itself completely, Medicaid funding for adults is nonexistent except for emergency procedures, and even then it’s limited to a single extraction for pain management. And while the Pew Charitable Trusts and the W.K. Kellogg Foundation have thrown money at the conversation by insisting that a midlevel provider would alleviate the problem, the resident model is a much better, less expensive, and easier fit. Winston says, “I’ve never worked with a midlevel provider, so I’ll say that off the top, but there’s no limit to what a resident can do legally – they all come from good dental schools, armed with a core set of skills they’ve been required to learn to graduate. These are people who have already invested a number of years in their education, and they take this very seriously. In our residency model, they are able to perform any skill that a licensed dentist can do, the only difference is that one of us has to be available to them, if they need it.” Letwin adds, “The thing to keep in mind is that a dentist graduating from dental school can go out and perform dentistry as they please. These are folks coming from dental school for additional training – but that doesn’t mean that they wouldn’t be able to treat patients on their own. You have no such guarantee with a midlevel provider.” Koday agrees, saying “I clearly believe in dentist-driven care, and one of the things I like about the residency program is that they are dentists – they have graduated from dental school, they are already well-trained and competent, and have a wide skill set, so all we’re really doing is broadening those skills and giving them more experiences. Residents do require supervision, but they can do far more complicated care and a wider range of procedures, so I don’t think there is any comparison at all. And when our residents have graduated they can go out on their own and continue to perform a very wide range of procedures, versus a very narrow set for the midlevels.”
In Eastern Washington, where it can be harder to get and keep good dentists in the CHC system, they had an idea: if they created a niche that combined education and community health, they might attract dentists from private practice who were more skilled. Reasoning that if dentists liked the niche they’d stay longer, they set out to design a residency program that would meet both targets. At the Yakima Valley Farm Workers Clinic, Dr. Mark Koday’s residency program began as an offshoot of a cooperative agreement with the UWSoD started in 1989 as part of a senior dental student rotation. He explains, “We had established a really good working relationship with the school and they agreed to cosponsor the residency program. They were a tremendous help in getting us started and keeping us going. And the other big supporter was WSDA – they were very helpful in getting us crucial, initial state funding, and have remained a strong supporter of the program. Without their support, I doubt if we could have pulled this off, and it certainly wouldn’t have been anywhere as easy or good as it turned out.”
Because of residency model they had created, they began to see a dramatic uptick in the quality of dentists applying to work in their clinic — skilled dentists from the private sector who were excited about teaching and mentoring the new generation of dentists. The gamble had worked. Having better dentists on staff benefits their patients, and it affects the staff in a good way, as well — and stabilizing the staff led to better continuity of care.
Now, Koday has dentists on staff producing between $800,000 and $1 million in gross production a year — something they had never done before. “We’ve figured out what we were doing right and what we were doing wrong,” Koday says, “And we’ve been able to fine tune the system really well, which also is good for the patients and the residents. For some time we had a revolving door — dentists would come for loan repayment and maybe stay a year or two. We no longer have that problem.”
Additionally, Koday says, “Before we started the residency I felt that I was isolated from organized dentistry — you had private practice, you had education, and you had community health — and the three practically never talked to each other. The thing that I really like about the program is that it is a combination of all three — we couldn’t do it without the private dentists who help us with the teaching, we couldn’t do it without the University of Washington, so it’s a dentist-driven team effort. I’m really sold on it as a way to increase access in the state of Washington.” At the clinic, they see two types of patients — emergencies, which they see every day — and patients of record, as you would see in any private practice. Having residents has enabled the facility to take more emergency patients, see more adults after the loss of adult dental Medicaid, and expand treatment to patients of record. Koday adds, “We never could have considered introducing implants or a number of the upper end procedures that we now offer without the residency program.”
When Bart Johnson and Amy Winston first submitted their proposal to Swedish, administrators there were not sure what to think. They were open minded to the concept, but wondered, “We’ve been around 100 years and never had a dental program, why do we need one now?’ Winston smiles as she relays the story — she and Johnson were undeterred, and the first year they did everything by themselves — including all of the emergency room and inpatient services. But after that first year, Swedish was sold — their hospital services and the cancer center had seen so much improvement that the Swedish doctors went to bat with the administration for the pair. Today, residents in the program are based in their private practice, with rotations at the Swedish SCSC extraction clinic, the Odessa Brown Pediatric Clinic, an anesthesia rotation, and an ER rotation at Swedish First Hill, each with their own attending dentists. “Now,” she says, “If you talk to Swedish they would say that we’re keeping people out of ERs, we’re taking care of people before they get to ICU, we’re making people healthy before they go in for cardiac surgery and transplant, and we’re improving the lives of their cancer patients — making it possible for them to successfully tolerate their treatments — which is critical for success. And now we can show other hospitals how these programs can be successful.” Johnson adds that while any community can benefit from their model, not every community will have a need for a practice treating the same patient population as theirs does. He says, “Our role in the community is that we take care of patients who are really challenging from a medical, behavioral, and physical standpoint, and we serve as a resource for the dentists and the medical doctors in this community – that’s the niche we fill for Seattle. The residency model is powerful because it allows different communities to identify what their needs are, and then building a residency that fills those needs. So I know the core model can certainly be duplicated, but the types of patients and the mission will be dependent on the geographic location.”
Dr. Taylor Berry, who is finishing up his year of residency at the Swedish GPR, says, “The quality of health care providers that these programs produce is so far above what comes out of dental school that I think it benefits everybody. We have new skills that we’re using, we’re more competitive in the job market, and we’re better educated and informed — which benefits the community. I can’t imagine having gone straight into private practice without the benefit of a program like this.”
So where do the residents go once their programs end? In Yakima, Koday did a survey a few years ago, and of the 40 graduates they were able to contact, about 70 percent had stayed in dental Health Professional Shortage Areas, including CHCs, and rural areas. “I think that more would have gone to that type of practice,” he says, “But when the economy fell and dentists weren’t retiring out, some of our graduates ended up in corporate practices because those were the only places hiring. We believe, as they do in the Regional Initiatives in Dental Education (RIDE) and Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) medical programs, that when you train residents in rural areas, a much higher percentage will stay in those areas.”
In Seattle, Winston and Johnson have seen their residents go into many different types of practices — “Two went on to specialize, one in pediatrics, one in orthodontics, the others have all become general dentists,” Winston continues, saying, “One went on to set up a practice very much like ours on a much smaller scale in rural Montana, working with cancer patients and doing general anesthesia. He’s bringing something to that Montana community that didn’t exist before — which is the ultimate goal of our program. The educational piece is huge – we’re laying the framework for the future of our profession. We’re providing care to the underfunded, and the program is incredibly educational. The investment is exponential, when you consider the number of graduates who will go out and do this type of work in private practice and have the skills to do it right.”
Danny Tremblay, who has spent the year commuting between Yakima and Seattle so that his wife, Rikki, could continue as a CPA in the city, is looking forward to becoming more involved in organized dentistry at the state and component levels. He hopes to join a private practice when he graduates, but not with just any dentist — he’s looking for a dentist who will continue to mentor him through his first years of practice, saying, “I believe that is so fundamental to the practice of dentistry — we’re always learning, and when you have someone who is willing to mentor you as I’ve been mentored this past year, you can have an even better experience in dentistry.” Tremblay also said that because of his experience in the CHC system, he’ll always make time to volunteer his expertise to them.
Taylor Berry has accepted a position as an attending dentist with the Swedish SCSC extraction clinic, and fellow resident Spivey is looking for an associateship here in Washington, preferably one where she can continue to use the complex skills she has acquired. In Spokane, Dr. Peter Dang has already begun working part time in a practice, and would like to continue to working in the community health system, as well. Fellow Spokane resident Dr. Kim Siler has signed a contract to be at a private practice in the area.
Each of the state’s residents is now armed with insight, education and skills they could never have received in dental school, creating scores of opportunities for access to populations that are woefully underserved. In contrast, midlevel providers offer only a narrow range of procedures without the benefit of the robust education a dental school provides. In Washington state, we’ve begun a dialogue about whether residency training should be mandatory and welcome your comments. Regardless of the outcome of that conversation, we’d like to ask you to join with WSDA in helping to create residency opportunities across the state — your voice will help make expansion of this program a reality. To find out how you can be involved, contact Bracken Killpack at firstname.lastname@example.org.