Behavioral Health Within Primary Care Postgraduate Dental Curricula: A Mixed Methods Study

Shenam Ticku; Tien Jiang; Hesham Alhazmi; Nora Alamer; Robin A. Harvan; Christine A. Riedy

doi:10.1370/afm.2931

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Table 1.

Characteristics of AEGD and GPR Program Directors and Their Programs

Characteristic	Surveyed Respondents, No. (%)	Interviewed Respondents, No. (%)
Program-level characteristics
Program type and duration
GPR, 12 months	67 (60.4)	9 (69.2)
GPR, 24 months	5 (4.5)	0 (0)
AEGD, 12 months	32 (28.8)	3 (23.1)
AEGD, 24 months	7 (6.3)	1 (7.7)
Time program has been training residents
0-5 years	4 (3.6)	1 (7.7)
6-10 years	7 (6.3)	1 (7.7)
11-15 years	10 (9.0)	2 (15.4)
≥16 years	90 (81.0)	9 (69.2)
Number of new residents matriculated into program each year
1-5	56 (50.5)	5 (38.5)
6-10	39 (35.1)	6 (46.2)
≥11	16 (14.4)	2 (15.4)
Clinical setting
Public hospital	29 (26.1)	4 (30.8)
Private hospital	25 (22.5)	2 (15.4)
University-based clinic	29 (26.1)	2 (15.4)
Other setting	31 (27.9)	5 (38.5)
Level of integrated BH care at residency’s primary clinical training site^{^a}
None	4 (3.6)	0 (0)
Minimal collaboration (eg, referrals and responses by fax only)	21 (18.9)	3 (23.1)
Basic collaboration at a distance (occasional direct communication)	24 (21.6)	1 (7.7)
Basic collaboration on site (BH professionals and dentists operate in parallel in same building with occasional face-to-face consultation)	24 (21.6)	2 (15.4)
Close collaboration on site with some systemic integration (same building, shared EHR, frequent face-to-face consultation)	24 (21.6)	5 (38.5)
Close collaboration approaching an integrated practice (formal same-day BH consultant, basic shared systems design for patient flow)	5 (4.5)	1 (7.7)
Full collaboration in a transformed/merged practice (fully integrated systems including population management, day-to-day care, and workflows)	9 (8.1)	1 (7.7)
Patients having social or economic hardships affecting dental care and compliance
0%-24%	19 (17.1)	3 (23.1)
25%-49%	16 (14.4)	0 (0)
50%-74%	47 (42.3)	6 (46.2)
75%-100%	29 (26.1)	4 (30.8)
Geographic location
Rural	3 (2.7)	1 (7.7)
Urban	42 (37.8)	8 (61.5)
Suburban	66 (59.5)	4 (30.8)
Census region
Midwest	20 (18.0)	4 (30.8)
Northeast	41 (36.9)	3 (23.1)
South	29 (26.1)	5 (38.5)
West	21 (18.9)	1 (7.7)
Individual-level characteristics
Age of program director
30-39 years	18 (17.7)	1 (9.1)
40-49 years	29 (28.4)	5 (45.5)
50-59 years	27 (26.5)	1 (9.1)
60-70 years	28 (27.5)	4 (36.4)
Sex of program director
Male	71 (64.0)	10 (76.9)
Female	32 (28.8)	3 (23.1)
Prefer not to say	8 (7.2)	0 (0)
Time program director has been in position
5 years	57 (51.4)	6 (46.2)
10 years	22 (19.8)	4 (30.8)
15 years	10 (9.0)	0 (0)
≥16 years	22 (19.8)	3 (23.1)

AEGD = Advanced Education in General Dentistry; BH = behavioral health; EHR = electronic health record; GPR = General Practice Residency.
Note: Analyses are based on 111 surveyed respondents and 13 interviewed respondents, except for age of program director, for which the values are 102 and 11, respectively.
↵a According to Substance Abuse and Mental Health Services Administration criteria.²⁴

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Table 2.

Program Directors’ Assessments of the Integration of Behavioral Health Training Into Their Curricula

Statement and Level of Agreement	Respondents, No. (%)
Statement and Level of Agreement	Eating Disorder	OUD	Depressive Disorder	Anxiety Disorder	IPV
Important for residents to receive training to identify the condition
Strongly disagree	2 (1.8)	4 (3.6)	4 (3.6)	4 (3.6)	5 (4.5)
Disagree	8 (7.2)	1 (0.9)	8 (7.2)	8 (7.2)	8 (7.2)
Neutral	26 (23.4)	9 (8.1)	21 (18.9)	21 (18.9)	26 (23.4)
Agree	29 (26.1)	21 (18.9)	30 (27.0)	35 (31.5)	32 (28.8)
Strongly agree	46 (41.4)	76 (68.5)	48 (43.2)	43 (38.7)	40 (36.0)
Important for residents to know community and/or health system resources to provide referrals
Strongly disagree	2 (1.8)	3 (2.7)	3 (2.7)	3 (2.7)	5 (4.5)
Disagree	7 (6.3)	5 (4.5)	6 (5.4)	6 (5.4)	5 (4.5)
Neutral	15 (13.5)	6 (5.4)	17 (15.3)	16 (14.4)	13 (11.7)
Agree	39 (35.1)	22 (19.8)	29 (26.1)	34 (30.6)	35 (31.5)
Strongly agree	48 (43.2)	75 (67.6)	56 (50.5)	52 (46.9)	53 (47.8)
Program includes curriculum that teaches resident to identify the condition
Yes	49 (44.1)	95 (85.6)	44 (39.6)	53 (47.8)	46 (41.4)
No	62 (55.9)	16 (14.4)	67 (60.4)	58 (52.3)	65 (58.6)
On graduation, residents are competent in identifying the condition^{^a}
Strongly disagree	1 (2.4)	0 (0)	0 (0)	1 (2.4)	1 (2.4)
Disagree	4 (9.5)	2 (4.8)	6 (14.3)	4 (9.5)	6 (14.3)
Neutral	14 (33.3)	5 (11.9)	10 (23.8)	10 (23.8)	15 (35.7)
Agree	14 (33.3)	13 (31.0)	17 (40.5)	15 (35.7)	14 (33.3)
Strongly agree	9 (21.4)	22 (52.4)	9 (21.4)	12 (28.6)	6 (14.3)
On graduation, residents are competent in knowing community and/or health system resources to provide referrals^{^a}
Strongly disagree	1 (2.4)	1 (2.4)	1 (2.4)	1 (2.4)	1 (2.4)
Disagree	3 (7.1)	1 (2.4)	3 (7.1)	2 (4.8)	4 (9.5)
Neutral	12 (28.6)	4 (9.5)	9 (21.4)	11 (26.2)	14 (33.3)
Agree	16 (38.1)	13 (31.0)	17 (40.5)	14 (33.3)	14 (33.3)
Strongly agree	10 (23.8)	23 (54.8)	12 (28.6)	14 (33.3)	9 (21.4)

AEGD = advanced education in graduate dentistry; BH = behavioral health; GPR = general practice residency; IPV = intimate partner violence; OUD = opioid use disorder.
Note: Analyses based on 111 respondents, unless otherwise noted.
↵a Question limited to the 42 respondents who reported that their residents were evaluated on BH content.

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Table 3.

Program Directors’ Description of the Integration of Behavioral Health Content in Their Program’s Curriculum

Aspect of BH Content	Respondents, No. (%)
How are the residents acquiring the BH content?
Lecture	81 (80.2)
Webinar/online modules	22 (21.8)
Case-based conferences	40 (39.6)
Grand rounds	17 (16.8)
Experiential learning through patient encounters	65 (64.4)
Other	6 (5.9)
Who is teaching the BH content?
Psychiatrist	12 (11.9)
Psychologist	15 (14.9)
Social worker	18 (17.8)
Licensed counsellor	8 (7.9)
Nonpsychiatrist board-certified physician	38 (37.6)
Medical resident	0 (0)
Nurse practitioner	7 (6.9)
Physician assistant	4 (4.0)
Dentist	88 (87.1)
Other	9 (8.9)
Are you evaluating the residents on BH content?
Yes	42 (41.6)
No	59 (58.4)
How are the residents evaluated on BH content?
Written/computer testing	10 (23.8)
OSCE or equivalent	3 (7.1)
Case presentation	21 (50.0)
Direct observation in clinical setting	37 (88.1)
Review of clinical documentation	26 (61.9)
What barriers prevent teaching of more BH content?
Lack of time in the curriculum/competing priorities	28 (27.7)
Lack of content experts	13 (12.9)
Lack of interest from faculty	4 (4.0)
Lack of department support	2 (2.0)
Not part of dental residency accreditation standards	10 (9.9)
Lack of university/hospital resources	3 (3.0)
Lack of community resources	3 (3.0)
Other	3 (3.0)

BH = behavioral health; OSCE = Objective Structured Clinical Examination.
Notes: Based on responses of 101 program directors, except for the questions about how residents are evaluated (42 program directors) and barriers (32 program directors). Respondents for each question may vary as the questionnaire followed a skip logic format.

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Table 4.

Factors Associated With Integration of Behavioral Health Content in the Curriculum

Outcome and Factor	Odds Ratio (95% CI)	P Value
Training to identify 3 or more BH conditions^{^a}
Level of BH Integration in program’s primary training site^{^b}
Close to full collaboration (referent)	1.00
Basic collaboration	0.66 (0.22-2.01)	.47
No to minimal collaboration	0.22 (0.05-0.92)	.04^{^c}
Age of program director
30-39 years (referent)	1.00
40-49 years	1.14 (0.26-5.03)	.86
50-59 years	7.57 (1.33-42.98)	.02^{^c}
≥60 years	2.88 (0.42-19.74)	.28
Training to identify depressive disorder
Level of BH Integration in program’s primary training site^{^b}
Close to full collaboration (referent)	1.00
Basic collaboration	0.39 (0.13-1.21)	.10
No to minimal collaboration	0.09 (0.02-0.47)	.004
Clinical setting
University-based setting (referent)	1.00
Multiple clinical settings	8.03 (1.03-62.83)	.047^{^c}
Training to identify anxiety disorder
Level of BH Integration in program’s primary training site^{^b}
Close to full collaboration (referent)	1.00
Basic collaboration	0.74 (0.24-2.23)	.59
No to minimal collaboration	0.17 (0.04-0.73)	.02^{^c}
Age of program director
30-39 years (referent)	1.00
40-49 years	2.27 (0.47-11.03)	.31
50-59 years	6.70 (1.10-40.63)	.04^{^c}
≥60 years	4.50 (0.49-41.66)	.18

BH = behavioral health.
↵a Out of 5 conditions (anxiety disorder, depressive disorder, eating disorder, opioid use disorder, intimate partner violence).
↵b See Table 1 for definitions. For this analysis, we combined the 2 basic categories and combined the 2 close categories.
↵c After applying Bonferroni correction, the P value was no longer statistically significant.

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Table 5.

Major Themes and Subthemes From Program Director Interviews

Theme and Subthemes	Respondents, No. (%)
Influence
Internal
Content driven by residents	2 (15.4)
Personal relationships	3 (23.1)
Content driven by program director	7 (53.8)
External
Proximity of clinics	6 (46.2)
Patient population	10 (76.9)
Standardization	11 (84.6)
Organizational influences	5 (38.5)
Funding/grants	2 (15.4)
Training strategies
Materials used
Literature	6 (46.2)
Experiential content	10 (76.9)
Standards	7 (53.8)
Screening tools	7 (53.8)
Teaching personnel
Interprofessional	3 (23.1)
Medical	2 (53.8)
Dental	6 (46.2)
Behavioral health	9 (69.2)
Public health official	2 (15.4)
Community health worker	1 (7.7)
Method of content delivery
Presentation	11 (84.6)
Direct patient care	10 (76.9)
Research project	1 (7.7)
Webinar	2 (15.4)
Community interaction	2 (15.4)
Interprofessional sessions	4 (30.8)
Location of teaching
Classroom	12 (92.3)
Clinical setting	10 (76.9)
Online	2 (15.4)
When/how much in curriculum
Training boot camp before start of residency	2 (15.4)
Uniformly throughout the year	4 (30.8)
Once a year	2 (15.4)
Amount of time in curriculum	5 (38.5)
Training outcomes
Evaluation technique
Observation in a clinical setting	6 (46.2)
Preevaluation and postevaluation	1 (7.7)
Postcourse examination	1 (7.7)
No evaluation	1 (7.7)
Observation in nonclinical setting	2 (15.4)
Impact
Treating patients comprehensively	5 (38.5)
Opportunities to participate as part of the interprofessional team	1 (7.7)
Make clinicians more empathetic	2 (15.4)
Share expertise in their future communities	1 (7.7)
Understand the role played by the dentist	1 (7.7)
Inclusive practice	1 (7.7)
Training output—success
Quantify success
Feedback from faculty and staff	1 (7.7)
Alumni questionnaire	1 (7.7)
Feedback from residents	1 (7.7)
Presenting at meetings	1 (7.7)
Awards	1 (7.7)
Models adopted elsewhere	1 (7.7)
Change in clinician practices	1 (7.7)
Successful treatment of patients with minimal supervision	1 (7.7)
Feedback from patients	1 (7.7)
Contributors to success
Physical proximity to physicians	1 (7.7)
Foundational relationships	3 (23.1)
Interest from resident	1 (7.7)
Various teaching methodology	1 (7.7)
Supportive leadership	1 (7.7)
Grants/funding	1 (7.7)
Faculty and staff	3 (23.1)
Program structure	2 (15.4)
State dental society	1 (7.7)
State government	1 (7.7)
Reasons for training strategies
Teaching personnel
Using subject matter experts	2 (15.4)
Method of content delivery
Rooted in patient care	3 (23.1)
Competencies used/not used
Current competencies ambiguous	1 (7.7)
Barriers
Not important to residents	4 (30.8)
Lack of faculty expertise/subject matter knowledge	6 (46.2)
Patient population	4 (30.8)
No referral source	3 (23.1)
Covered by state licensure	1 (7.7)
No reimbursement in organized dentistry	1 (7.7)
Culture	7 (53.9)
Organizational barrier	4 (30.8)
Cost	1 (7.7)
Time	10 (76.9)
Miscellaneous	1 (7.7)
Solutions to barriers
Educate around stigma, for cultural change	1 (7.7)
Collaborate with subject matter expert	1 (7.7)
Pique resident interest	1 (7.7)
Reflections
Incorporate new training methods	1 (7.7)
Understands future potential of content inclusion in curriculum	3 (23.1)