The Effects of Collaboration in a Progressive Rural Dental Model

The Effects of Collaboration in a Progressive Rural Dental Model

Michael Zakula, D.D.S.* and Jerome Pedersen, D.D.S.**:
The Hibbing Dental Clinic is a model for outreach programs everywhere. Said one instructor, "I believe the dental students leave Hibbing with a new appreciation for what it is to be a dentist".

Michael Zakula, D.D.S.

Sometimes being in the right place at the right time with the right people yields a collaborative spirit, and all the pieces fall into place. Such was the case in Northeastern Minnesota in late 1995. What began as a discussion during the Open Pit Dental Study Club in Hibbing, Minnesota, resulted in the establishment of a dental clinic, a collaborative effort between the University of Minnesota, Hibbing Community College, and Iron Range dental professionals.

The discussion at that study club meeting centered around a survey that Dr. Cam Jayson of Virginia had compiled. Due to the “graying” of the local dental professional population, it was clear that the region would be faced with a severe shortage of dentists in the near future if left unaddressed. The immediacy of the need to attract dentists to the Iron Range stayed with me, only to be highlighted just two weeks later at an Executive Council meeting of the Northeastern District Dental Society (NEDDS). Once again, a lengthy discussion ensued relating to the need to address the severity of the access to care problem our region was beginning to experience prior to the anticipated retirement of a major percentage of currently practicing dentists in Northeastern Minnesota. The impending need for action was foremost in my mind.

A few weeks after the NEDDS meeting, a possible solution for dental access to care came to mind after attending a meeting of the Advisory Board of the dental assisting program at Hibbing Technical College. Ken Simberg, Chief Academic Officer of Hibbing Technical College, gave the board an update on the planned merger of Hibbing Community College and Hibbing Technical College. He explained that there would be a new dental lab and clinic area built in the proposed addition to the existing structure of Hibbing Community College. This clinic would house the dental assisting program. Driving home after the advisory board meeting, I began to question why this clinic couldn’t be expanded into a fully functioning dental clinic, using dental and dental assisting students, under the supervision of a licensed dentist, to provide dental services for the underserved. The training of these dental and dental assisting students in a true clinical setting would enhance their educational experiences and at the same time provide an invaluable service to the local population. Additionally, it would give dental students a true taste of “rural dentistry” which might in turn whet their appetites for setting up their own practices in a rural setting after graduating from dental school. Although my idea had an air of improbability attached to it, my inability to turn a blind eye to the issue of access to dental care led me to pursue it on several fronts.

The next day, I contacted Dr. Michael Till, Dean of the University of Minnesota (U of M) School of Dentistry, to share my vision. He was very positive about the idea of expanding the role of the dental clinic at Hibbing Community College and felt that it was a good fit for his mission of the U of M Dental School carrying a lead position in advocacy for rural dentistry. After an in-depth exchange of ideas, Dr. Till agreed to take our proposal to key persons at the University and see if he could gain philosophical, academic, and financial support. Money would be a key issue. I agreed to approach local and regional figures and explore their willingness to support the expansion of this clinic’s mission.

We wasted no time in moving forward. Dr. Anthony Kuznik, Hibbing Community College president, graciously agreed to meet with me the very next day. He was acutely aware of the current dental access problem in St. Louis County due his current membership on the St. Louis County Public Health Committee. Dr. Kuznik was excited about the concept and hoped that his 14-year position as Vice Chancellor at the University of Minnesota/Crookston would facilitate the process. He agreed to work in tandem with Dr. Till, who immediately presented this vision to Mark Yudov, University of Minnesota president; Bob Bruininks, University of Minnesota vice-president, and University Academic Health Science Center vice-president Dr. Frank Cerra. Tacit approval to investigate the details of the concept of a rural dual-venture dental clinic was given with a directive to “see where it goes”.

 



"The clinic's evolution has gone from busy to busier", states Director Jerry Pedersen.

As the process played out, Dr. Frank Cerra gave his full endorsement and provided significant financial support in the amount of $50,000.00, which was critical to advancing the project. This brought the University of Minnesota Dental School on board, naming Dr. David Born as Project Director. Dr. Born and Dr. Daniel Rose, University of Minnesota Outreach Coordinator, became the University’s spokespersons, and along with Dr. Till advanced the process by doing on-site forums, exploring the concept with the dentists of Hibbing and the surrounding regions. The forums highlighted the fears of many local dentists that this Hibbing Community College/U of M dental clinic could have an adverse affect on their practices and serve to be a source of competition. Dr. Till’s strong advocacy for the concept, explanation of the depth of the dental care access problem in our region, openness, and pledge that he and his staff would be willing to come back to the Iron Range at any time to hear their concerns and hammer out solutions put all fears to rest. To ensure against any recurrence of unfounded concerns, active efforts by Drs. Matt Anzelc, Richard Johnson, and Carl Schneider in lobbying fellow colleagues and local legislators moved the cause forward and brought the Minnesota Dental Association into an active advocacy role as well. The only obstacle left was money.

In order for the merger of Hibbing Community College and Hibbing Technical College along with this progressive dental clinic to become a reality, the Minnesota state legislature needed to pass a 24 million dollar bonding bill. Area dentists, the Minnesota Dental Association, Hibbing Community College, and the University of Minnesota School of Dentistry aggressively lobbied Minnesota state legislators. Senator Jerry Janesich and Representatives Dave Tomassoni and Tom Rukavina worked tirelessly to earn the support and passage of this bill. This unprecedented team effort of academic institutions, dental professionals and their organization, and state legislators won the final approval for provision of requested funds in toto in 1998, just three years from the origin of this experimental concept.

The University of Minnesota Dental Clinic at Hibbing Community College became a reality in January of 2002. Once the construction of the facility was completed, the School of Dentistry hired Dr. Jerome Pedersen, a local Hibbing dentist, to serve as director of the clinic. He has done an excellent job in gearing the clinic setting more toward a rural private practice, as opposed to the old model of an institutional clinic. The dental students who rotate through the clinic are given direct exposure to the classic dental problems they will face as they begin their professional careers. Their experiences at this rural clinic give them a true taste of hands-on rural dentistry, hopefully making them more well informed on the pluses that rural life can offer developing dental professionals. If this aspect is realized, the ultimate regional goal of increasing public access to dental care will be accomplished.

Another goal of the original plan has been realized. The clinic also serves as a portal for distance learning via teledentistry and Clinical Grand Rounds. These technological entities provide excellent continuing education opportunities for the local dental community. Training of dental assistants continues at the clinic, but with the added enhancement of actual experience in assisting of primary dental care providers from the onset of their training.

Iron Range dentists are extremely appreciative of the School of Dentistry’s willingness to “step up to the bar” and foster support for rural dentistry by tangibly addressing the access to care problem. Area dentists have established a $1,500.00 annual dental scholarship in the name of Dr. Michael Till to help entice new dentists to establish their practices in our region. The extended benefits of this collaborative rural dental clinic continue to pay themselves forward.

Looking back, the real turning point for this project, beyond winning state funding, was the coming together of Drs. Kuznik and Till. It was clear that the melding of minds and energies between these two accomplished academics and administrators would bring this project to fruition. Rumor has it that the final clinic design was scripted on a napkin at the Hibbing Park Hotel during the 11th hour of the architectural planning of the new addition to the HCC educational complex during a meeting between the two. They shared a crystal clear vision of the potential that this clinic had to transform the delivery of rural dental care to those without access, and both were willing to assume an active role in making it a reality well ahead of its time. Perhaps it was their shared ties as alumni of the University of Iowa that allowed them to trust and respect one another to the point of being receptive to a practitioner’s concerns and theories regarding solutions and moving on to create a national model for rural dental health care delivery. Their efforts also achieved the first successful venture between the University of Minnesota Health Science Center and the MnSCU (Minnesota State Colleges and University) system.

The need to recruit new dentists to rural areas and address the dental access problem will continue to challenge our profession and each of us as individuals. But this collaborative rural clinic model is experiencing its seventh year of success in addressing the mission to provide greater access to care for the people of Northeastern Minnesota and the bridging of gaps between top- and middle-level academics, urban and rural practitioners, and students and professionals. The University of Minnesota Dental Clinic at Hibbing Community College is the pride of the University, the Community College, and its surrounding communities. It is a “shining star” of academic collaboration as it provides a top notch clinical training site for tomorrow’s dentists, dental hygienists and dental assistants; a link for experienced dentists to the teaching of their skills and discipline in roles as adjunct faculty assisting Dr. Pedersen and the students; and it serves the greater rural public addressing the dental care needs of area residents, particularly those who are underserved. Although this rural dental clinic is not the only answer to access to care in and of itself, it is a model that has set the stage for further collaboration between the dental professions, academia, and government greatly needed in the quest to solve the long-term issues involved with access to adequate dental health care.

 


Said Dr. Robert Lew, "The Clinic is a great symbiotic relationship for the community and the students".

Dr. Jerome Pedersen has been Director of the Hibbing Dental Clinic from 2002 to the present. Northwest Dentistry asked him to paint the picture of the clinic’s remarkable success in its seven years of operation.


NWD: How many patients have been treated since the Hibbing Dental Clinic opened its doors?
Dr. Pedersen: Five thousand three hundred and thirty-eight. The numbers increase yearly and are absolutely sustainable. The clinic schedules emergency appointments that fit into the schedule, as we are a critical access provider. We take new patients into the regular schedule when needed, and at this time I am anticipating numbers will increase due to the bad economy.
NWD: Who is the typical patient?
Dr. Pedersen: Seventy-three percent of our patients come from state programs, 19% are fee-for-service, and 8% are under regular dental insurance. Forty percent are male, 60% female. Twenty-seven percent are children 19 and under, 53% adults, and 20% seniors.
NWD: What is the source of funding?
Dr. Pedersen: Funding comes from what we can produce doing dentistry, and from the University of Minnesota’s Academic Health Center.
NWD: How large is the drawing/referral area?
Dr. Pedersen: Most patients come from within a 50 mile radius. However, the clinic does have a few patients who travel as much as three hours.
NWD: How has this program been accepted by local dentists?
Dr. Pedersen: Very positively. Several of the local dentists have become adjunct faculty for the School of Dentistry. Others use the clinic as a source of continuing education credits, with the Grand Rounds program received at no charge at this time from the School of Dentistry at the Minneapolis campus. Still others have referred patients to the clinic for general dentistry needs.
NWD: How has this program influenced the HCC Dental Assisting program?
Dr. Pedersen: I believe that the University’s program has enhanced the overall Dental Assisting Program, and the Dental Assisting Program has done the same for the University’s program through the sharing of the facility that was built and equipment that has been purchased. No one program could have afforded to purchase the equipment or the facility that is now available to the students. Truly, the shared facility was innovative for its time, and credit needs to be given to Drs. Michael Till and the past president of the Hibbing Community College, Anthony Kuznik, for their foresightedness.
NWD: Have new dentists been drawn to the area due to this experience?
Dr. Pedersen: This is a difficult question to answer. The area has received many new dentists since the Hibbing program opened. However, many factors have to be considered when answering this question. I believe it can best be answered by the young dentists who have located in this area.
NWD: How did the clinic evolve compared to what you were hoping for?
Dr. Pedersen: I did not know what to expect, nor did the staff who were hired for the Hibbing Clinic. I believe the School of Dentistry was optimistic about and excited by the challenge of opening a stable-site outreach facility, but was also nervous about the long distance between the main campus and Hibbing. When hired, I was told that this might be a temporary position, and the School would see how things would develop. I was told that the staff also needed to know when hired that their positions might also be temporary. After seven and a half years of operation, our positions are now secured, and the original staff has grown from three to six. The full-time staff now includes a dentist, a business manager, two dental assistants, a hygienist, and a receptionist.


The clinic presently has several Adjunct Dentists who come in on a regular basis. They are Drs. Robert Lew, John Zupancic, William Kubiak, and Kimberly Lindquist. Past Adjunct Dentists include Drs. Cavour Johnson, Michael Zakula, Carl Schneider, Richard Johnson, William Magajna, Pamela Perell, David Perell, Sonal Koratkar, Duncan Puffer, Thomas Seidelmann, Marty Espi, Michael Miskovich, Peter Miskovich, Timothy Langguth, and Cameron Jayson.


It should be noted that the Hibbing Outreach Clinic could not have functioned without the help of all present and past Adjunct Dentists. The clinic’s evolution has gone from busy to busier, as the demand for services never seems to decrease. All involved were pleasantly surprised by the numbers of patients who wanted to access the clinic’s services. Demand for services continues today, and at the present time the clinic has to turn away patients for regular dental care.


Dr. Bill Kubiak describes the clinic as "An absolutely wonderful learning environment preparing students for the "real world.'"

The Auxiliary Component
Northwest Dentistry queried Hibbing Community College Dental Assisting Director Anne Badjanek and HCC dental assisting instructor Candace Clark about the impact the Clinic has had on their work since its inception.

“It all began with Head Start,” they told us. “They contacted the University of Minnesota about the possibility of opening a clinic here, since their needs could not be met locally. As to why this model is so effective, this clinic takes care of a population that was formerly not underserved, but unserved. Now we have the advantage of a very modern dental clinic. Our student dental assistants have the opportunity to work with student dentists. They are able to observe many diverse procedures while on campus, as opposed to having to wait until their spring internships. We have also been able to share the cost of some of the equipment.”

From the HCC side, the clinic’s evolution has gone forward a starting point of students doing mechanical polishes for new patients. However, “since the clinic is not able to accept new patients at this time, our students bring their own patients in. Thus we are not helping with production the way we did in the beginning.”

As for the clinic’s overall success, “It has been a very successful endeavor. It helps recruit dental assistant students to the program. It has helped an underserved population in the community access dental care. And we believe it has increased the number of new dentists moving to rural Minnesota. Having a full-time dentist on the staff has been extremely valuable to our program,” they continued. “The professionalism of the dentist, staff, and students goes hand in hand with the reputation of HCC’s dental assistant program.”

A Heart for the Work
Northwest Dentistry asked a number of Hibbing Clinic dentists and students past and present about the idea as it started and the work as it continues, and we received a very positive picture of a model project. They told us:

“Placing the clinic in an area of high need I’m sure opened the eyes of a lot of students. The problems they have to deal with are more varied and severe. With the excellent and experienced staff from the private sector, the clinic is run every bit as an ordinary office would be - an absolutely wonderful learning environment preparing students for the ‘real world’. As far as its success, it certainly fills the need for which it was intended. As a retired practitioner, I have enjoyed meeting and dealing with the younger people coming up. I find great pleasure in imparting tricks and techniques to make life easier for them.”
Dr. William Kubiak


“The Hibbing Clinic model works because of the dedicated, caring staff led by an outstanding director, Dr. Jerry Pedersen. The support of the community and University is a plus. It is a great symbiotic relationship for the community and the students. This model is clinically effective for many reasons, chief among them the diverse population it sees: elderly, medically compromised, pediatric, handicapped, checkered pasts including crime and drug/substance abuse, varied socioeconomic standing - all being treated harmoniously within a small group practice setting. Truly mimicking a real-life group practice office setting, it allows the students to blend all phases of general dentistry during the treatment of their patients. Unlike school, the setting is not departmentalized. The students are able to accomplish more treatment per patient visit due to the favorable student-to-teacher ratio, meaning less wait time for progress checks and mentoring. The students have the opportunity to experience procedures, equipment, and materials that they may not have been exposed to at the School. The void this clinic fills in the underserved population of the area receiving dental care is immeasurable. Many patients travel more than an hour to receive care here.

“I rate the clinic as very successful, a solid model for other projects. Student comments are also a testimony to the clinic’s success, as are the appreciation of its patients, and the satisfaction the practitioners receive is a tribute to the clinic.”
Dr. Robert Lew


“I came to Northeastern Minnesota to practice endodontics in 2005, and began teaching at the Dental Clinic in 2007. I believe a big reason the program is such a success is its Director, Dr. Pedersen. He is truly a patient advocate as well as a knowledgeable and enthusiastic instructor. When he became director he was able to bring many of his former staff with him, and their teamwork really helps this outreach clinic run like a private dental office. Certainly students see a variety of patients, but they also experience real computerized dental records, digital radiography, and hygiene exams. Since the dental students do not have the convenience of on-site specialty care as they do at the School, they are challenged with a variety of difficult cases, which is a great way to help them realize their strengths and weaknesses before graduation. I believe the dental students leave Hibbing with a new appreciation for what it is to ‘be a dentist.’”
Dr. Kimberly Lindquist


“During my last semester of dental school I had the opportunity to spend four months at the clinic when it officially opened, under the guidance of Dr. Pedersen. Running it just like a start-up private practice, with the help of great clinical staff and dental assisting students, we were very productive. There were a lot of acute needs in the beginning. Just prior to his wedding, we saw a patient who had rampant caries, and he was embarrassed to smile. Dr. Tim Jacobson spent several long appointments to make it possible for him to smile proudly on his wedding day. I think everyone involved at the Hibbing Clinic feels very good about what can be, and is being, accomplished there.

“I had, as well, the opportunity to work with an oral surgeon, Dr. Tom Seidelmann, who came to the clinic when more difficult surgical cases presented themselves.”
Dr. Timothy Isaacson


“Why did I choose Hibbing? It gave me the opportunity to be immersed in Greater (rural) Minnesota, not only location, but in the amount of time a student was able to invest. We were able to see more patients in a day than at the U’s main campus, and this gave us a greater sense of impact and community service. This was such an excellent experience. We were able to ‘put it all together’ - the ‘mix ‘n match’ procedures, from fillings to emergencies to extractions and root canals, all in the same day. We learned how to shift gears and envision what private practice would demand of us. This was intimidating, but with the smaller class size, personalized instruction, and support from Dr. Pedersen, it was possible to gain the confidence many of us needed to feel complete in our educations.”
Dr. Nathan Pedersen


“I was in Hibbing in August 2002 for a clinical externship, then again as a participant in the Rural Health School Program there in 2003 for an extended period of time. I thoroughly enjoyed the experience. In school I usually saw two patients a day; in Hibbing I saw six to ten.

“I chose Hibbing in order to see if I would like it enough to complete my graduation requirements early and stay for the Rural Health School program, and I was not disappointed. Dr. Jerry Pedersen is a phenomenal teacher and mentor. In school it had been “teacher/student”; in Hibbing it was “experienced doctor/new doctor”. This was the first time I was referred to as “doctor” in front of my patients, and it boosted my confidence and, I believe, their confidence in me as well. As well, because Hibbing operates like a general practice, switching from surgical to operative to diagnosing skills multiple times a day was both exhilarating and confidence building.

“I was already considering a rural practice, and Hibbing confirmed my decision, not only for its location, but for the fact that the experience I obtained made me comfortable and confident treating patients on my own in my own practice. I was the only person in my class to go from school to opening my practice from scratch, and part of that had to do with my Hibbing experience. When I went to the bank for a loan, I already had an idea of what my production would be, and that I would be able to pay my loans and financially support my own practice.

“Hibbing also afforded me the opportunity to work with the dental assisting students. As students ourselves, we appreciate any assistance, since we are used to ‘having to do it on our own’. I think the dental assisting students found it comfortable and reassuring to work with us as well.

“Most of the patients I saw at the Hibbing Clinic were on some sort of state assistance program. It opened my eyes to the huge need that there is for education and dentistry in this population. I am a volunteer dentist at Caring Hands Dental Clinic in Alexandria, where we see a similar population of patients.”
Dr. Kimberly Rauk


Said one of the clinic’s architects, “There were lots of inquiries about how it was done, and it was concluded that what was needed is the heart for the work.”

And There’s a Scholarship
Area dentists have established a $1,500.00 annual dental scholarship in the name of Dr. Michael Till to further invite interest in practicing in the region.