No ordinary lesson

They treated victims of abuse, and people who had lost everything after some unforeseen, devastating crisis. They treated prostitutes and drug users who measure time by the number of days since their last fix. They treated people living on the streets who used every last cent they had on a meal, not a toothbrush.

They were at times met with anger and impatience, were sometimes yelled at and cursed, but were also blessed and thanked.

They treated, they listened. They nervously confronted their own stereotypes. And now, they say, they feel ready to become dentists.

All fourth-year dental students must complete more than 31 days of clinical rotations in San Antonio and South Texas before graduating. Yet there’s one clinic that is met with both dread and anticipation. The mandatory rotation is at San Antonio Christian Dental Clinic at Haven for Hope, which provides free dental care for homeless and underserved adults and gives the students a unique patient pool with challenges rarely, if ever, experienced by students, said Vidal Balderas, D.D.S., M.P.H., assistant professor of comprehensive dentistry.

“Most students have never had the opportunity to be a part of cases where they’re exposed to [post-traumatic stress disorder], addiction, bipolar disorders—sometimes all in the same patient,” he said. “Our primary goal of the experience at San Antonio Christian Dental Clinic is to expose our students to patients whose lives have been compromised. It’s almost assured that at least one of those experiences with the patients we deal with there will be heart-wrenching. You can’t help it. When you’re homeless, something devastating put you on the streets.”

Haven for Hope has served more than 6,870 residents since it opened in 2010. In that time, they have accounted for 2,800 visits to San Antonio Christian Dental Clinic.

“For many, the nature of poverty and homelessness becomes tangible at San Antonio Christian Dental Clinic,” said Gloria Canseco, executive director of the clinic. “Students come face-to-face with profound cases of patients who have suffered from domestic violence, substance abuse, mental health, abandonment and other severe obstacles to healthy lives. At the same time, students are also dealing with people who have made a commitment to recovery, demonstrating courage and resolve in the face of daunting circumstances.”

It’s not your average rotation, Dr. Balderas said, so School of Dentistry faculty don’t treat it as one. Before students begin at the clinic, they are prepped about situations they may face. They’re shown the panic buttons affixed to hallway walls. They’re told to watch out for signs of “meth mouth,” the so-called calling card of the methamphetamine user, who often has decay in every tooth. They’re trained to look for the signs of a detoxing addict, whose behavior can swing radically from mellow to aggressive like a flip of a switch.

And they’re told they must not pre-judge their patients.

“It doesn’t matter what they look like, how they talk, what their language is. You treat them with respect. Members experiencing homelessness at Haven for Hope come from all walks of life,” Dr. Balderas said. “You’ve got people with master’s degrees and Ph.D.’s who were living on the streets.”

When the rotation is over, the students meet around a lunch table and reflect on the experience, led by Moshtagh Farokhi, D.D.S., M.P.H. FAGD, clinical assistant professor in comprehensive dentistry, who also works with the students at the clinic. What would they have done differently? How did they treat their most compromised patients? What was the hardest situation they faced?

Then they tour the Haven for Hope campus and get a glimpse at the lives their patients lead.

In essays, they write about their experience.

In her own words

“I assumed that the patients would be out of control and I would fear for my safety. Honestly, I am embarrassed that I felt nervous or scared about the idea of working on these patients. This impression completely changed over the course of the rotation. Many patients…did not appear to be any different from myself. This experience reminded me to look at patients as a whole and unique individual rather than letting the homelessness define the individual.”–Mary Grace Camp, student

Mary Grace Camp, a fourth-year dental student, readily admits she has thin skin. She was nervous about the rotation at the clinic, and expected the worst.

Two days into her rotation, while trying to get the medical history of a male patient, he began yelling, frustrated about the amount of time he had been waiting.

“I got a little upset, but I tried to stay professional and said ‘I would appreciate it if you don’t use that language with me,’” she said. She and Dr. Balderas calmed the patient, and he got through the appointment. But strangely for Camp, she said, she felt encouraged by the experience, not overwhelmed. She realized she was not helpless, but that many of her patients feel that they are. It gave her a better understanding of where they were coming from.

“Some of my patients were really thankful to be there and thankful to have someone take care of them,” she said. “I feel like every patient was just ecstatic to have treatment done.”

In most cases, they’ve never been taken care of before, said Dr. Farokhi. The U.S. Department of Housing and Urban Development reported that in 2014, San Antonio’s homeless population cited dental care as its highest need. Only 14 percent reported receiving the dental care they needed.

“They don’t have money. They don’t live in a warm house or apartment like you. They’ve been on the streets,” Dr. Farokhi said. “So when you give them attention and you’re polite and professional toward them, you are likely the first one that has done so. Then you do all this work. You take them out of pain, you remove their source of infection and you are courteous to them. That’s why they are so appreciative. You make a difference in their lives.”

Five years ago, the School of Dentistry faculty asked their pre-doctorate students if they would be interested in volunteering a half day once a week at the clinic. Their jobs would be similar to what is done routinely in the School of Dentistry’s eight clinics—exams, fillings and extractions. The response was overwhelming and unexpected. More than half of the fourth-year dental students signed up. The one critique faculty received repeatedly: One half-day a week wasn’t enough.

Eventually, the volunteer opportunity became a required weeklong rotation, funded through annual support from Methodist Healthcare Ministries. After collecting three years of reflection papers, Dr. Balderas said, it’s now obvious students want even more. Faculty are considering extending the pre-doctorate rotation to two weeks.

In the meantime, the school has expanded its services at San Antonio Christian Dental Clinic by adding residents in the advanced education in general dentistry program. Twice a week, they do more extensive dental work, such as root canals and surgical extractions. Dental hygiene students have also joined the rotation, providing cleanings and oral disease prevention education. Last year, 223 students, residents and faculty provided more than half of all dental services at the clinic.

“I see this as an opportunity for them in a tough environment to learn how to treat the most difficult behaviors in a positive manner,” Dr. Balderas said. “It’s a learning experience. Some of them go through a week without any major things, but they get to at least hear a story. They get the chance to validate someone’s life.”

 

Learning from experience

The rotation at San Antonio Christian Dental Clinic revealed a few surprises for Camp. One of them was how deeply she was touched by the stories she heard from her patients. They didn’t just give her a renewed appreciation for what she has, but they also reminded her that as a dentist, she’ll have a duty to help others who can’t help themselves.

“No one is immune to emergencies and disasters we can’t control that drain us of resources, financially and emotionally,” she said.

According to the clinic, an estimated 130 million people lack dental insurance in the U.S. Locally, less than half—41 percent—of Bexar County residents reported seeing a dentist in the past year. Compounding the problem, Bexar County and surrounding counties in the region are considered “dental deserts,” where the dentist-to-patient ratio is lower than that of the national average.

The patient load is higher for the students at San Antonio Christian Dental Clinic than at the clinics offered at the School of Dentistry. A typical day at the clinic can have up to five patients scheduled per dental student, plus emergencies. This is about two to three times higher than a typical day at the university’s clinics.

“For our part, the partnership [with the Health Science Center] extends our capacity for direct patient care, nearly doubling the numbers of underserved patients we treat,” Canseco said. The clinic has no paid dentists on staff, beyond its director of dental services. “The partnership guarantees a minimum threshold for capacity and assures a level of excellence on par with that of an academic health science center. And at a higher level, working with underserved patients contributes to the development of a social conscience for the students.”

These are lessons that can’t be fully taught in the classroom, said Dr. Farokhi. Life lessons. At San Antonio Christian Dental Clinic, it’s as real as it gets.

“I see more aha moments in these rotations than I ever do in the classroom,” she said. “But everything that is learned [at San Antonio Christian Dental Clinic] is true about all patients. Every patient has their own unique story. One shoe does not fit all.”