Fall 2013

Building a Health-Care Home

One patient, many providers— and a fresh approach to bringing it all together

By Helene Ragovin

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Illustration: Stuart Bradford

The dentist eyes her patient’s red, spongy gums. she knows he was diagnosed some years ago with Type 2 diabetes, and now the condition of his mouth tells her that his blood-glucose levels are likely not as well-controlled as they should be.

Ideally, the patient would go off to see an endocrinologist, primary-care physician or nurse practitioner who, perhaps with the help of a registered dietitian or certified diabetes educator, would work to get his levels under control. Those looking toward the future, however, envision a time when dentists, physicians, nutritionists, nurses, pharmacists and a host of other health-care professionals are educated to work side by side in an integrated system that patients would know as their “health home.”

In concert with a trend gaining currency throughout academic dentistry, Tufts School of Dental Medicine is turning significant attention to this health-care model, known as interprofessional education, or IPE. It’s a future that in some ways is still slow in coming, and no one’s predicting the demise of the traditional dental practice. But it’s also a future that is just around the corner—and those responsible for sending new dentists into the world of 21st-century health care say the profession has to be prepared.

“These are changes that will impact dental school graduates for their careers over the coming decades. Can we afford not to be part of this?” asked Judith Buchanan, professor of prosthodontics at the University of Minnesota, in addressing a roomful of Tufts dental faculty this summer. Buchanan was involved in establishing an IPE framework at Minnesota, which was one of the first academic health centers to embrace the concept, and which now anchors an academic consortium devoted to the subject.

At Tufts, Dean Huw Thomas and his administration have embarked on an IPE initiative on several fronts—most notably establishing a director of IPE position, funded with a grant from the DentaQuest Foundation. The School of Dental Medicine has reached out to its sister schools at Tufts and to other health sciences schools and organizations in the region with an eye toward partnerships. At a symposium on IPE hosted at Tufts earlier this year, representatives of nearly a dozen Boston-area institutions sat around a table, eagerly exchanging ideas and forging connections.

“The focus at a number of academic institutions is to move the educational process out of the siloed way in which it currently occurs … to a movement to enhance the interactions of all health professions students.” —Richard Valachovic, ADEA

“We know that students are often unclear about the background and expertise of their colleagues from other disciplines,” says the school’s IPE director, Ellen Patterson. “Bringing students together—whether to discuss a case, to participate in a clinical simulation or to provide direct patient care—builds their medical knowledge base while fostering an appreciation for the complementary roles they’ll play in patient-centered health care.” Patterson’s own career has bridged broad areas of the health sciences. She is a psychiatrist who has worked in private practice, in-patient facilities and substance abuse programs; she also has a master’s degree in health communications and worked for a health technology company.

“All health professionals need specific communication and teamwork skills to be effective members of interdisciplinary teams,” she says. And, she adds, these skills are best taught through hands-on experiences.

Such endeavors are not entirely new to Tufts dental school, which was one of the first to capitalize on the connections between oral health and nutrition. Tufts was among the first dental schools to have a physician on the faculty. Through an externship program, dental students interact with colleagues at community health centers; at service projects, such as the Sharewood Clinic, they volunteer alongside peers from the university’s other health sciences schools.

In fact, the idea of reaching beyond disciplines echoes the “One Medicine” philosophy of Tufts’ transformative president, Jean Mayer, who led the university from 1976 to 1992. “Any time you can break down the silos of higher education, particularly in the health sciences, you’re doing good,” says Sol Gittleman, the Alice and Nathan Gantcher University Professor who served as provost during much of Mayer’s tenure. Traditional academic training, Gittleman says, has encouraged solo effort. Now, new knowledge and technologies are demanding interaction. “We need a new culture,” he says.

Great Expectations

Interprofessionalism in health care is evolving along two tracks, says Richard Valachovic, president and chief executive officer of the American Dental Education Association (ADEA) and a member of the dental school’s board of advisors. “The focus at a number of academic institutions is to move the educational process out of the siloed way in which it currently occurs—medicine taught independently from nursing from pharmacy and so on—to a movement to enhance the interactions of all health professions students,” he says.

Equally important, Valachovic adds, are the ways in which the nation’s largest health-care delivery systems—the Veterans Administration and Kaiser Permanente among them—are adopting team-based approaches to patient care, motivated by both market forces and the Affordable Care Act. The result is that leaders in health care expect new graduates to be educated in an interprofessional, collaborative way.

Another push toward IPE at all U.S. dental schools is a new component of the requirements set by the Commission on Dental Accreditation. The standards, which went into effect earlier this year, call for evidence of interaction within the higher-education and health-care systems, and graduates who are competent at communicating and collaborating with members of the health-care team.

Back in the 1960s, there was some nascent interest among health sciences educators in what was then called interdisciplinary education, says Barbara Brandt, director of the National Coordinating Center for Interprofessional Education and Collaborative Practice, a consortium founded in 2012 with funding from public and private sources to promote IPE. (ADEA was among the founding organizations.)

But, the ’60s were also the beginning of the era of specialization. “There was little interest in the care-delivery process,” Brandt says. “There was no alignment between education and practice, and no research on the subject.” Even at Tufts, where students from the dental, medical and veterinary schools took basic science classes together in the 1970s—a practice dictated at the time as much by financial necessity as pedagogical philosophy—that model did not necessarily lead to collaboration outside the classroom.

Those lessons are reflected in the way IPE is viewed today. The emphasis is not about having students from different disciplines sit together in the same room, stresses Carole Palmer, G69, a nutritionist who served as acting director of IPE at the School of Dental Medicine. The key is understanding each other’s place in the health-care system and learning to collaborate and find ways to resolve conflict, she says.

“What we learned is that if people do not interact, they really do not understand what their roles are,” says Palmer, a professor and head of the dental school’s division of nutrition and oral health promotion, who also holds appointments at Tufts’ medical and nutrition schools.

Consider the experiences of Gregory Lane, D13. He came to the dental school with an appreciation of the value of interdisciplinary work—as an undergraduate majoring in anthropology at Northwestern University, he did his senior thesis in archaeology. At Tufts, he developed an interest in geriatric dentistry, which led him to Professor Hilde Tillman, D49, who for more than a decade has been bringing dental students to a psychiatric unit at Tufts Medical Center to attend to the patients’ oral health. From there, Lane became part of a research team working in the psych unit with faculty and students from the department of occupational therapy in Tufts’ Graduate School of Arts and Sciences.

Yet, Lane says, it’s not until you’re actually out on the floor, side by side with the others, that you develop a real sense of diverse perspectives. “It’s so easy to get locked into one way of thinking when you’re always talking to people who know the same things,” he says. Working with those outside dentistry, “you have to teach them about what you do, and they have to teach you about what they do. It’s not always easy for someone who’s educated on one specific topic to develop another frame of reference, but you have to be open; you have to value the other person and what they do.”

For example, it wasn’t until Lane was at the medical center that he had the chance to learn about the full extent of what an otolaryngologist—an ear, nose and throat specialist—does. “I had no idea they could repair broken facial bones,” says Lane, who entered private practice after graduation. “Now, if I have someone in the chair, and something seems irregular, I can say, ‘Maybe you should see this type of doctor.’ And if you as a dentist have a relationship with that doctor, that’s even better.”

 ‘Physicians of  the Oral Cavity’

Indeed, what dentists bring to the table is their unique role as “gatekeepers of health,” as Dean Thomas likes to describe them. “Patients come to see us more regularly than any other health-care provider,” says Carole Palmer. “Most diseases have clinical manifestations in the mouth. Oral tissue turns over more rapidly. We see evidence of diabetes, eating disorders, leukemia and many other medical conditions.” Thus, integrating dentistry with the other health sciences can help increase access to care, as patients will be more easily able to move within a “health home.”

“We are training students to be physicians of the oral cavity,” says Kanchan Ganda, professor and head of the division of medicine at the dental school. “We are no longer the drill, fill and bill type of dentist.” Since 1980, Ganda, a physician, has been teaching medicine courses to Tufts dental students.

Ganda’s role was a rarity among dental schools when she started at Tufts. Then, following a 1995 Institute of Medicine (IOM) report that recommended closer integration of dentistry and medicine, her role became a model. “Dentistry had always been focused on the teeth and mouth. Tying it into medical education was not a priority at that time,” Ganda says. After the IOM report, “everybody was trying to see how best we could do it. We were already doing it at Tufts.”

Outside of academia, the integration of dentistry and other health-care fields will not be without hurdles. Historically, dentistry has been modeled on the independent practice. Many more dentists are working in group practices than in the past, yet those practices—even ones with dozens of clinicians on hand—are still limited to dentists and those in the allied dental professions.

In this way, dentistry remains distinctly different from medicine. Nearly 60 percent of physicians are now employees of health-care delivery systems, according to ADEA’s Valachovic.

“Marcus Welby has taken down his shingle,” he notes.

A report released earlier this year by the American Dental Association analyzing critical trends for the profession examined this phenomenon. “Care is being integrated within ‘patient-centered medical homes’ in medicine, but inclusion of dental care services has been slow,” the report concludes. “It will take time for the medical system to recognize the need to expand the concept of health and incorporate nonmedical personnel. It will also require dental professionals to evolve from being dental practitioners to being responsible for overall oral health of patients.”

This, Valachovic says, is where the new generation of graduates comes in. “This generation coming out, the millennials, are people who desire much more to work in teams,” he says. Bolstered by IPE curricula and hands-on learning experiences, these new dentists will be primed for the future.

 

 

Dental Education with a Side of Nutrition

 

When the outspoken nutritionist Jean Mayer arrived as president of Tufts University in 1976, he found a receptive audience at the School of Dental Medicine. That was in part because the school—a pioneer for the time—had an already-established interest in nutrition and its intersection with oral health.

“The dental school was the only school interested in nutrition when Mayer showed up,” recalls University Professor Sol Gittleman, who served as provost under Mayer. In fact, the Tufts dentists stood alone not just at the university, but among their peers at other U.S. dental schools, Gittleman says. “Nobody was up [for] nutrition the way they were.”

Abraham Nizel, A38, D40, DG52, who joined the faculty in 1946, specialized in integrating nutrition assessment with dental practice, and was the author of three classic texts in the field. Before arriving at the School of Dental Medicine in 1974, Athena Papas, J66, now the Erling Johansen Professor of Dental Research, worked at MIT with Hamish Munro, who later became the first director of the Jean Mayer USDA Human Nutrition Research Center at Tufts; she continues to conduct nutrition-related research.

Since 1965, students from the combined dietetic internship and master’s program of the Frances Stern Nutrition Center at Tufts Medical Center and the Friedman School of Nutrition have been coming to One Kneeland Street as part of their training. After she graduated from the program in 1969, Carole Palmer, a registered dietitian, joined the dental school as an instructor. She had come to Nizel’s attention while completing a rotation at the dental clinics, and quickly made the intersection of nutrition and oral health the foundation of her career.

Palmer, now a professor of diagnosis and health promotion who also has appointments in the School of Medicine and the Friedman School, has taught hundreds of dental students about the relationship between nutrition and oral health. When the publisher Prentice Hall needed someone to write an updated dental nutrition textbook to succeed Nizel’s, it naturally turned to Palmer, who published Diet and Nutrition in Oral Health in 2002. It is in its third edition.

“Dentists, from the year one, have been telling their patients, ‘stay away from sweets,’ but that’s a great oversimplification,” she says. “In fact, the aspects of diet that affect oral health are more complicated.”

The partnership between the dental school and Frances Stern is a perfect launching pad for additional interprofessional activity, says Palmer, who served as interim director of interprofessional education. “This was primarily under the radar, and now with such interest, it’s the perfect environment to strengthen that rotation and do even more,” she says.

Pavel Zeylikman, D14, who was paired with a nutrition student in the clinic last spring, echoes that, saying he wishes more of his classmates could have shared the experience. “I think each one of us [in the dental class] could benefit from having nutrition students around,” he says. He recalled one of his patients who lost nine pounds over the course of the rotation, a happy byproduct of nutrition counseling. “You’re using the teeth we fix to chew that food,” he says.   —Helene Ragovin

 

 

Dentists Join Attack on Childhood Obesity

 

Virginia Chomitz, N85, N92, an assistant professor of public health and community medicine at Tufts School of Medicine, knows a lot about the suboptimal American diet, but even she was appalled when she attended a talk about what children under age 2 are eating. The average toddler diet is heavy on hot dogs, cookies, sugary drinks and other processed foods.

Their diets, she says, “are dreadful.”

Clearly, parents need some guidance. But how to intervene? Because many of the same foods that lead to obesity also tend to be rough on teeth, Chomitz reasoned that a good place to start the conversation may be the dentist’s office.

After all, children typically see their dentists for preventive care twice a year for scheduled cleanings, whereas they generally see their physicians for an annual checkup, she says. Physicians also have to cover a laundry list of health topics during a physical, whereas dentists and hygienists tend to have more time to talk during cleanings.

With that in mind, Chomitz has teamed with colleagues from dentistry, medicine, public health and nutrition to pilot a project at the Tufts Dental Baby Clinic called Baby Steps to Health. The interdisciplinary team is devising a way—easily integrated into an appointment—for dentists to talk with parents about proper nutrition for a healthy weight and good oral health.

The Tufts Clinical and Translational Science Institute has given a $25,000 Catalyst Award for the project, which is drawing on the expertise of Carole Palmer, G69, professor and head of the division of nutrition and oral health promotion at the School of Dental Medicine; Cheen Loo, DI10, an associate professor of pediatric dentistry; Hubert Park, D11, a resident in pediatric dentistry; and Mary Tavares, D77, a senior clinical investigator at the Forsyth Institute; as well as Aviva Must, Susan Koch-Weser and Kenneth Chui from the School of Medicine’s department of public health and community medicine; and M.E. Malone, a graduate student in nutrition and public health.

The team has been fine-tuning a questionnaire that parents will be asked to fill out in the waiting room before they meet with their child’s dentist. The dental team and the parents can review it together and set some healthy eating/healthy teeth goals. The wording of the questionnaire is important, because the team does not want parents to feel overwhelmed, or wonder why they are being grilled about nutrition at the dental office.

“We are trying to hone in on the intersection where dentistry and nutrition really meet,” says Park, who is managing the project in the clinic.

Park, who is also pursuing a master’s in public health at Tufts, said he already has learned a lot from sitting at the table with health experts from across the university. “That’s really the beauty of the study—multiple investigators from different backgrounds coming together,” he says. “That is exactly what I’ve been hoping for. When different experts come together, you definitely get a better quality product.”   —Julie Flaherty

 

 

A Physician Finds Her Niche

 

In 1980, Kanchan Ganda was a new mother of twin girls, with a degree in medicine but little interest in returning to work full time. Her friend Norman Stearns, a physician and an administrator at Tufts Medical School, was looking for someone to take over a course on how to take medical histories that he had been teaching at the School of Dental Medicine. Ganda agreed.

Then, she notes, “one thing led to another.” Thirty-three years later, Ganda is a professor, head of the division of medicine and medical consultant for the pre- and postdoctoral dental clinics. “I came here by accident, but I stayed by choice,” says Ganda, who trained in anesthesiology in Mumbai. During her early days at Tufts, she established a medical education program that for many years was unique among dental schools.

Even before the Institute of Medicine and the U.S. Surgeon General released their landmark reports in 1995 and 2000 that stressed the connections between oral health and overall health, Ganda was convinced that Tufts dental students should be getting a solid grounding in medical science—how to take a medical history, common diseases and their symptoms, interpreting lab reports, pharmacology, prescription writing, dealing with medically complex patients—early in their dental school careers, and certainly before they hit the clinics in the third year.

Ganda also initiated a series of five-week clerkships for dental students at Tufts Medical Center. “They get a good understanding of how physicians work on the other side,” she says. And while they are in the medical center, the students can perform oral exams on any patients who may need them. “It’s a two-way dialogue between our students and the people on the other side—they, in turn, are learning about the oral cavity,” Ganda says.

This year, Ganda founded the LOTUS community service program, which stands for Linkage of Tufts University Students. Her co-investigators are Aruna Ramesh, DI04, an associate professor of diagnosis and health promotion, and Ruby Ghaffari, D92, an assistant professor in that same department. The goal of LOTUS is to establish a clinic for the nearly 1,500 underserved residents at the Castle Square apartments in Boston’s Chinatown neighborhood. The project launched with screenings conducted by dental students and medical residents from the ear, nose and throat program at Tufts Medical Center. The eventual goal is to establish a clinic spearheaded by dental student volunteers, similar to the Sharewood Clinic in Malden, Mass., run by Tufts medical school students.

“I would really like for the dental students, medical students, nutrition students, hygiene students [from the Forsyth School of Dental Hygiene] to all get involved and create an external interprofessional education experience for themselves and one that also helps the community,” Ganda says. “Our student body is completely ready for this. All the disciplines working together as a team for the betterment of the patients—that is going to be the norm.”   —Helene Ragovin

 

 

 

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