Allan J. Formicola, DDS, MS
The dean emeritus of Columbia University’s College of Dental Medicine and community health advocate talks about what influenced his passion for public health.
INSIDE DENTISTRY (ID): As a former dean of the Columbia University College of Dental Medicine, whose “legacy” may well be your role in the community medicine movement, how did you parlay a career in academics into one as a community medicine activist? Who were some of the people who influenced you early in your career, and what influenced you at Columbia to get involved with community health?
ALLAN J. FORMICOLA (AJF): I learned much that helped me in my career in academia from those who influenced and challenged me. Standing on their shoulders, I have grown far beyond the traditional professional career expectations I had when I entered Georgetown Dental School in 1959. I have benefitted greatly from the mentorship of many during my years in dental school, postdoctoral training, and the early parts of my career. Two people at Georgetown especially influenced me—periodontics department chairman Peter Ferrigno and anatomy department chairman Baldev (Raj) Bhussry—because they took an interest in my research on radioisotopes. That allowed me to explore the development of the periodontium in a very dynamic and exciting way. Mentors from my days at the University of Alabama included Wallace Mann and Bob Caldwell, and at the University of Medicine and Dentistry of New Jersey, where I was chairman of the department of periodontics and associate dean for academic affairs, Dean Ian Bennett. They each became role models for me because of their similar visions to mine with regard to teaching philosophy, dental education, and research.
At Columbia, where I was the dean of the College of Dental Medicine for 23 years, I was inspired by the excellence of the faculty, staff, and student body. They always motivated me to make improvements to move the college forward. In the Columbia environment in New York City, I gained a broader sense of what was expected of us in academia and what could be accomplished outside the classroom. For example, I received many calls for help from the local schools in the neighborhood whose principals described students sitting in their offices with swollen jaws or tooth pain for which treatment was unavailable. Of course, children can’t learn when they’re in pain. This prompted us to develop what we call the Community DentCare Network at Columbia, in which the College of Dental Medicine set up programs to reach these children through a network of eight school-based clinics, a mobile van, and community-affiliated practices and clinics, which helped relieve a major health issue in the community. That was in the late 1980s and the1990s.
When I stepped out of the deanship at Columbia in 2001, I became further involved with community health. For the last 10 years of my career at Columbia, I worked closely with community organizations and the faculty at the medical center and hospital under a Kellogg Foundation program called Community Voices. The purpose of the program was to improve the safety net for underserved and uninsured people.
ID: As founder of the Center for Community Health Partnerships, which merged with the Center for Family Medicine, what were its purposes and achievements, including its impact on dental education in the United States?
AJF: I’ve always been interested in helping our profession find ways to deal with community health issues. I believe that dental schools and the profession at large must be proactive at going into the community, talking with the residents, and building approaches to help reduce disease and promote health in the population. Illustrating the importance of such efforts is a harrowing description of the pain and suffering caused by untreated dental problems and other health issues among the uninsured in the interview-based book Uninsured in America.1 The Center for Community Health Partnerships provided the platform to reach out to the underserved in the community and nationally.
In 2000, for example, my colleague Howard Bailit from the University of Connecticut and I developed a community-based dental education program called Pipeline, Profession & Practice: Community-Based Dental Education (The Dental Pipeline) program. For this national program, we received the largest foundation funded grant in the history of dental education from the Robert Wood Johnson Foundation in collaboration with the California Endowment Foundation and the Kellogg Foundation. Under that program, over a 10-year period, we were able to award grants to 23 dental schools for two purposes—first to develop community-based education programs for their students, and second to increase the enrollment of underrepresented minority students.
The Dental Pipeline program was highly successful. The 23 schools involved developed community-based education programs by affiliating with off-site community health centers and increasing the amount of time that senior students spent in caring for underserved populations, from an average of 10 days at the beginning of our project, to 50 days at the end. The schools understood that community-based education involved more than just sending students out for rotations. They developed preparatory coursework in cultural competency and communication skills so that the students obtained the necessary knowledge to approach the community with sensitivity. In addition to deepening the students’ education on the needs of the underserved, the students were able to provide 129,000 dental services to almost 69,000 patients in just 1 year. Students who participated became more confident in their skills, and faculty reported their clinical abilities had markedly improved after having this experience.
In keeping with the other goal of the project—to increase the enrollment of underrepresented minority students in dental school—the minority student population grew by 54% among the first 15 schools involved during the first 5-year phase of the program as a result of improved recruitment programs on campuses with large numbers of minority students.
In addition to the funding received to launch The Dental Pipeline program, the Center for Community Health Partnerships at Columbia received a 3-year grant from the Josiah Macy Jr. Foundation in 2004 to explore new educational models or strategies to provide schools with the resources needed to strengthen their educational, research, and service programs, as well as to examine the growing financial problems of dental schools. A special issue of the Journal of Dental Education reports on the accomplishments of this grant program.2
ID: How can we encourage more dental students to similarly rise to the challenges of the day both in dental education as academics and in otherwise moving the profession forward? Should students pursue research while in dental school?
AJF: I see two main ways faculty can inspire students to take on future challenges. First, it is critically important for faculty to be available to talk with and listen to students—that is, to serve as mentors. Second, how faculty members conduct themselves and interact with students in the classroom or clinic as role models is important. If faculty use up-to-date teaching methods, encourage students’ questions, treat students as junior colleagues, and create a stimulating, positive learning environment, it might encourage students to see a career in academia as satisfying. The environment we create within the schools—a place where questioning, curiosity, and creativity are important—can motivate students to take on the important issues of the times.
Regarding student research, part of our mission is to produce thinking graduates prepared to increase the knowledge in the profession. Therefore, it is important that students have the opportunity to do research. For some students, this might involve laboratory research to explore basic and clinical problems. All students should be encouraged to think through a problem, prepare reviews of the literature, or write papers on important topics while in school.
Some dental schools are more research-intense than others, but I consider it an obligation of all dental schools to create a climate where students are expected to engage in some type of scholarly pursuit. Student research organizations can help create this climate, and schools should support such efforts.
ID: How have dental schools changed over the years?
AJF: Dental schools continue to stress a strong biologic base for clinical education. In addition, there have been several major movements that have improved dental education. In the late 1960s and the 1970s, the comprehensive care movement in clinical education set a standard in dental education for considering the whole patient’s needs, not just the individual dental problems. Next, case-based teaching methods have encouraged the development of problem-solving skills in students. New technology has made the learning environment much more self-paced and interesting for students, moving away from the rigid memorization of the past. Over the past two to three decades, the inclusion of electives in the curriculum and required courses in subjects such as the behavior sciences, cultural competence, communication skills, and community-based education have enriched the curriculum, preparing graduates for the issues and the problems they will face in contemporary US society.
Another change is a recognition that a more diverse student body contributes to a more active learning environment. When I entered dental school almost 50 years ago, there were no women or minorities in our classes. Dentistry has become an attractive profession for women, and they now account for 47% of the entering students. While the number of underrepresented minority student applicants to dental schools has increased somewhat, there is still a great need to enroll more underrepresented students for the profession to be more inclusive of the US society. Only 5% of those enrolled in dental schools in 2010 were African-American, and approximately 7% were Hispanic.
Something that hasn’t changed much are the great challenges posed by financial pressures and a shortage of faculty. However, in spite of these problems, dental schools continue to improve the learning environment for their students.
ID: How can dental schools address staff diversity and faculty shortages?
AJF: Recent surveys showed that there have been between 300 and 400 unfilled funded full-time positions in dental schools. Currently, the number of underrepresented minority faculty is low, and as schools strive for diversity in their students, they need to make it a priority to reach out to fill faculty positions with underrepresented minority faculty members. To encourage an interest in academia among graduates, some schools offer their students specific programs that combine dental education and advanced education in pedagogy. Grants to develop the next generation of research faculty are provided by the National Institute of Dental and Craniofacial Research. There are also loan paybacks for full-time service on the faculty. These programs should be continued and expanded in order to bring a new generation of full-time faculty into dental education. The vitality of the profession depends upon the next generation, who will have new ideas in teaching, research, and practice.
To fill current gaps, schools have also been very successful in recruiting more full-time faculty from private practice, developing orientation programs for their new roles in teaching so they can be as effective in the classroom as in their practices. Schools have also been able to recruit part-time faculty members—also from private practice—to fill gaps in the clinical education teaching staff. These, full- and part-time faculty come with years of practice experience and bring great expertise in clinical dentistry to the clinical teaching programs. These are some of the ways schools have been coping with shortages.
ID: You have also been a proponent of interprofessional education. What is this and how does it serve dentistry?
AJF: Interprofessional education involves two or more professions’ learning together to improve collaboration in practice and improve the quality of patient care. This approach encourages students to learn about the other health professions, how they work, and how they fit into the broader scheme of treating the more complex patients seeking care. It involves actively learning together with those in medicine, nursing, social work, and other fields while in school, which ultimately promotes more communication between professions.
The interprofessional education movement is a way to create integration of coursework needed by various health science professions. This means not only sitting in the same classrooms, but also involving groups of students from different fields in active learning in subjects like cultural competence and communication skills.
The Community Voices project showed me the importance of enlisting social work, public health, and a growing field of community health workers to deal with improving community health. Familiarizing those fields with what we do, and vice versa, as well as making them aware of how we contribute to primary healthcare, takes collaboration at all levels—in academia, in practice, and in the community. I think this is the best way we can deliver better health to our citizens, and it begins while students are in school.
ID: What is involved in bringing disparate groups together to meet the challenges of improving oral healthcare?
AJF: My colleague, Dr. Lourdes Hernandez-Cordero from the Mailman School of Public Health at Columbia, and I described what we learned while working with many different groups, across disciplines, and with the community during the last 10 years of my career at Columbia in our book, Mobilizing the Community For Better Health: What the Rest of America can Learn From Northern Manhattan.3 We concluded with the simple finding that the best way to bring different groups together is through good communication and trust between people. There is no substitute for sitting down together to discuss and work out problems of mutual concern. While there are many barriers to getting the community and institutions working together, when there is trust between people and the goals between the community and the institutions are in harmony, progress can be made in improving the community health system.
Regarding improving oral health, it is my belief that the movement toward interprofessional education will improve the atmosphere, ushering in a new era of working closely between the medical and dental professions and other the other professions that are part of the healthcare team. We found that to be the case in northern Manhattan. When we involved the entire community, the local and city government, and the institutions in the problems of poor oral health in the children, we were able to find ways to reach those in need. By bringing together the local schools, Head Start centers, and the resources available in the institutions, and with the help of funds from grants, private donors, and the dental industry, we were able to develop a program that now provides over 50,000 patient visits in the community each year.
References
1. Starr Sered S, Fernandopulle R. Uninsured in America: Life and Death in the Land of Opportunity. Berkley, California: University of California Press, 2006.
2. Formicola AJ, Balit HL, Tryfon J, et al. Introduction to the Macy Study Report. J Dent Ed. 2008;72(2 Suppl):5-9.
3. Formicola A, Hernandez-Cordero L, eds. Mobilizing the Community For Better Health: What the Rest of America can Learn From Northern Manhattan, New York, New York: Columbia University Press, 2008.
About Dr. Formicola
Currently professor emeritus and dean emeritus, Columbia University, College of Dental Medicine and Center for Family and Community Medicine, Dr. Formicola was the founder of the Center for Community Health Partnerships, which merged into the Center for Family and Community Medicine. Dr. Formicola initiated the collaboration between Columbia University Medical Center, Alianza Dominicana, and Harlem Hospital Medical Center to establish the Northern Manhattan Community Voices Collaboration. He currently directs or co-directs a number of national foundation projects dealing with oral health disparities and a lack of access to dental care.
