ISSUE
               
The Future Is Interdisciplinary
Bringing a Psychosocial Perspective to Education, Research, and Patient Care


Professor Karen Raphael




Dr. Hillary Broder




Professor Victoria Raveis




Donna E. Shelley, MD, MPH




Recently, a trio of distinguished social scientists with strong public health backgrounds joined the NYUCD faculty, thereby strengthening NYUCD's efforts to foster an interdisciplinary approach to improving healthcare education and delivery. Professors Hillary Broder, Karen Raphael, and Victoria Raveis (profiled in this article) are talented researchers and educators, whose work reflects the importance of attitudes, health behaviors, and social determinants of health in providing patient care. Together with Dr. Donna Shelley, Director of Interdisciplinary Research and Practice for the Colleges of Dentistry and Nursing, they form a distinctive social sciences research group.

Professor Hillary Broder

"Nobody cares how much you know, until they know how much you care," says Dr. Hillary Broder, Professor of Cariology & Comprehensive Care. In October, Professor Broder introduced a new communications training program utilizing live actors working with third-year dental students, and a communications competency in patient management for fourth-year students. The goal is to make students mindful of their interpersonal skills as the key to achieving a good relationship with their patients, and, ultimately, to increasing patient retention.

"By enhancing students' interpersonal skills," says Dr. Broder, "they are more likely to have better relationships with their patients; be less likely to be ‘disappointed' by patients not showing up; and be more successful when they graduate and go into private practice."

Professor Broder's program is grounded in psychological theory and communication-her area of teaching expertise. Formerly the Acting Chair of the Department of Community Health at the UMDNJ-New Jersey Dental School and the Hunterdon Endowed Professor of Community Health at UMDNJ, Professor Broder earned a master's degree in educational psychology and a PhD in school/counseling psychology from Duke University. She has a long record of achievement in communications in health care and community outreach to diverse patient groups and has published extensively in the Journal of Dental Education and other scholarly venues on promoting interpersonal skills and cultural sensitivity among dental students.

In the third-year clinical communications program, students interview professional actors who portray various types of patients; for example, a patient with dental anxiety, a patient who is inebriated. Each student interviews three patient-actors within the two-hour session and receives feedback on their performance from the patient-actor, who uses a calibrated instrument to measure patient-doctor communication and to grade the student regarding the salient content data extracted during the interview. Through this process, students begin to see how they are being perceived by their patients. After three sessions with three different actors, the students will have completed the interview portion of the program.

Later that day, they attend a seminar led by Professor Broder or one of the other NYUCD faculty members whom she has trained. During the seminar, pertinent patient management issues are reviewed and the students' challenges are discussed.

"Every patient interview," says Professor Broder, "is a cross-cultural encounter. The objective is to teach students to promote patient-centered care and understand that patients are diverse and communication must be tailored to address patient concerns. It is crucial that students be respectful and mindful that every interaction is unique and not project their own values during the interview, but, instead, project objectivity, compassion, and empathy for the patient. It takes more than technical competence to be successful in the field of dentistry. The dentist must always remember that the mouth is a private area, and many emotions surround the idea of intrusion into this area. There are also privacy issues associated with patients' medical and social histories."

While many medical schools-but not dental schools -offer a course in patient communications, what makes the NYUCD program unique is the fact that students receive immediate feedback and begin to understand how to manage patients better. The medical school programs focus primarily on medical diagnosis while the NYUCD program addresses interpersonal communication. Students are taught the skills that predict whether patients like their doctors and will return for care.

Professor Broder is also recruiting and training clinical faculty to evaluate senior dental students' interviewing skills. The goal is to have approximately 20 calibrated faculty from the Departments of Oral & Maxillofacial Pathology, Radiology & Medicine and Cariology & Comprehensive Care. When a senior student sees a patient for the first time, one of the calibrated faculty members will sit with that student and oversee the patient interview and give the student feedback regarding the observed patient-doctor interaction.

Given that current senior students will not have had the didactic training in their third year. Professor Broder anticipates a very exciting research opportunity to examine skills over time as the junior students advance into the fourth-year program.

"My challenge," says Professor Broder, " has been not only teaching the actors to perform their roles as patients, but also training the faculty. But it's a thrilling challenge, one destined to lead to a win-win for the student, the patient, and NYUCD. I really thank Dr. Mark Wolff, Professor and Chair of the Department of Cariology & Comprehensive Care and Associate Dean for Predoctoral Clinical Education, for this exciting opportunity."

In addition to her teaching, Professor Broder is considered a world-class research expert in psychosocial aspects of craniofacial rehabilitation and care planning. She is currently the principal investigator of an NIH-supported grant entitled "Quality of Life in Children with Cleft."

"We are using the Child Oral Health Impact Profile (COHIP) and various other instruments to examine the impact of surgical outcome on children with craniofacial conditions." It is noteworthy that Dr. Broder is the primary author of the COHIP. This instrument was developed under a previous NIH grant with Dr. Broder as the principal investigator. The instrument is utilized in multiple studies nationally and internationally to evaluate oral health-related quality of life.

Her current investigation includes an interdisciplinary team across six renowned clinical sites (e.g., NYU Center for Reconstructive and Plastic Surgery, University of North Carolina, Children's Hospital of Philadelphia at the University of Pennsylvania, University of Illinois at Chicago, Lancaster Cleft Palate Center, and Children's Hospital of Atlanta). This five-year longitudinal prospective study is the first of its kind to investigate surgical outcomes like oral health-related quality of life among school-aged children.

Professor Karen Raphael

For Dr. Karen G. Raphael, formerly a Professor of Psychiatry and Director of Research in the Department of Psychiatry at the New Jersey Medical School of the University of Medicine and Dentistry of New Jersey, finding an answer to the question, "What really causes TMD-type facial pain?" is a reflection of her broader interest and background in behavioral, clinical, and epidemiological research aimed at teasing apart biological, psychological, and sociological risk factors as they affect the manifestation of medically unexplained conditions, such as fibromyalgia (pain all over), as well as TMD-type pain.

Dr. Raphael, who joined NYUCD in 2009 as a Professor of Oral & Maxillofacial Pathology, Radiology & Medicine, holds both a PhD in psychology and a master's degree in epidemiology.

"Although temporomandibular muscle and joint disorders ("TMJ" or "TMD") are one of the most common musculoskeletal pain conditions, with annual associated healthcare costs estimated to exceed $4 billion, their treatment has been hindered by controversies about their underlying cause," explains Professor Raphael. "At NYUCD, we are midway through a five-year, NIH-funded study designed to provide much needed evidence that has the potential either to support or to refute widespread beliefs about their cause."

One theory is that TMD pain is caused by grinding or clenching of the teeth ("bruxism"), either at night or during the day. Working with a national and international team of scientists, Dr. Raphael and Dr. David Sirois, Associate Professor of Oral & Maxillofacial Pathology, Radiology & Medicine and Associate Dean for Postgraduate Programs, are studying a large group of TMD patients and controls for evidence of bruxism. Participants are studied while they are asleep in a sleep laboratory, during which their muscle activity is recorded by electromyography and audiovisual recording and then scored for presence, extent, and type of sleep bruxism. Their daytime muscle activity is also studied, while they are exposed to a series of mild psychological stressors. DNA samples are also collected, to test the possibility that bruxism alone is not enough: Perhaps a combination of specific genetic predispositions and bruxism is necessary for people to develop TMD pain.

A second major theory is that the central nervous system of TMD patients processes painful stimuli differently than individuals without TMD. The team is also studying this theory, by recording subjective sensations of pain, when patients and controls are exposed to a series of heated stimuli applied to the face and hand.

One possibility is that different factors cause or maintain pain for different subgroups of TMD patients. This would explain why a "one size fits all" treatment like oral appliance therapy does not help many patients. If the team confirms this hypothesis, it sets the stage for the development and testing of treatments targeted to specific underlying pain-maintenance mechanisms.

Professor Raphael's worldview is all about being interdisciplinary, which is reflected in her collaboration with Professor Hillary Broder in the clinical communications program, as well as in her research.

Professor Raphael collaborates with Professor Broder in training patient-actors in appropriate behaviors in various true-to-life doctor/patient scenarios, meeting with small groups of third-year students to review the feedback they have received from the patient-actors, and debriefing them on their experiences. She also trains faculty members to evaluate students' interviewing skills in an actual clinic setting during their senior year.

Professor Raphael's teaching responsibilities perfectly complement her research interests. Since she recruits many of her research patients through the Department of Oral & Maxillofacial Pathology, Radiology & Medicine and the Department of Oral & Maxillofacial Surgery's pain service, the students she teaches to be better clinical communicators can help her identify people who are seeking relief from muscle pain.

Professor Raphael also interfaces with the Department of Orthodontics through Dr. John Dolan, a recently appointed Assistant Professor of Orthodontics, who has developed an animal model of mastication and pain that Professor Raphael hopes can serve as a bridge to the clinical model of mastication and pain that she has developed.

Professor Raphael's interests also include the epidemiology of TMD pain, the way that psychiatric and pain disorders group together in families, and the genetic environment in which TMD pain develops-all areas that are rich for exploration and for which NYUCD's dense patient population offers abundant research potential.

Professor Victoria Raveis

Dr. Victoria H. Raveis joined the NYUCD faculty in January 2010, as a Research Professor in the Department of Cariology & Comprehensive Care and Director of NYUCD's newly established Psychosocial Research Unit on Health, Aging, and the Community-the first program of its kind in a dental school. She was formerly an Associate Professor of Clinical Sociomedical Sciences at Columbia University's Mailman School of Public Health, Director of the School's Aging and Public Health Program, and Co-Director of Columbia's Center for the Psychosocial Study of Health and Illness. Professor Raveis holds a master's degree in sociology from Boston College, and a master of philosophy degree in sociology and a PhD in sociology, both from Columbia University.

A medical sociologist and a social gerontologist, Professor Raveis brought her Columbia University research team with her to NYUCD, a multidisciplinary group that includes a social-personality psychologist, a health educator, a demographer/statistician, and applied social science and social psychology researchers. Together, they focus on the psychosocial aspects of chronic and acute disease and the public health components of healthy aging, with special attention to family-focused disease management programs and palliative services for vulnerable and medically underserved communities.

"Globally," says Professor Raveis, "our population is aging, and the health professions and society as a whole are not fully prepared to deal with the changes this demographic shift will impose. One of my long-standing goals is to infuse a lifespan perspective into the curriculum for the health sciences. People are living longer due in part to advances in health promotion and disease prevention beginning in the womb. Healthy aging is really a lifelong process, so it's particularly important to be able to identify when and where community populations experience health threats, barriers to care, and how to overcome them. That's the mission of my unit.

"Being located at a dental school is particularly beneficial because dentistry as a profession primarily deals with a healthy population. With the added benefit of a Nursing Faculty Practice located within the dental school, the opportunities for early intervention multiply," says Professor Raveis.

Recognizing the importance of giving attention to the factors that enable or prevent people from having their health needs addressed, Professor Raveis is currently focusing on two major research initiatives. One initiative deals with enhancing family caregivers' skills in addressing the needs of older cancer survivors. The second study seeks to reinvent senior centers to make them more relevant to the looming influx of aging baby boomers.

With support from the National Institutes of Health (NIH) and the National Cancer Institute (NCI), Professor Raveis and her team are working with the family caregivers of older cancer survivors recruited from Naturally Occurring Retirement Communities (NORCs) to provide caregivers with skills to attend to the symptom management and care needs present during the post-treatment, cancer survivorship period.

"When you're a patient in active treatment in a medical setting," explains Professor Raveis, "symptom management and specialty care are more accessible. But post-treatment, once the patient is home, contact with medical providers is limited and the care issues that emerge over time often fall to family members. We are working with family members to enhance their problem-solving and communication skills, helping them attend to the varied issues that may emerge, enhancing both quality of life and quality of care during the survivorship period.

"For example," she notes, "in some cultures, chronic pain is regarded as something to be endured. Such beliefs can hinder symptom management efforts and prolong suffering. By addressing post-cancer-treatment patients' physical and emotional needs in a culturally sensitive manner, their quality of life may be substantially enhanced."

Professor Raveis's other major research interest, for which she is currently pursuing funding, involves a collaboration with the Council for Senior Centers and Services of New York City, Inc., (CSCS) and the International Longevity Center, Inc., (ILC) to promote healthy aging by repositioning senior centers as centers of wellness.

Those elders who are using senior centers are rapidly aging. Today, individuals in their 70s and mid-60s lead more active lives, says Professor Raveis, and are looking for meaningful activities that will sustain their health and promote well-being.

Building on the existing framework of senior centers, but focusing more pointedly on a healthy aging perspective, Professor Raveis and her colleagues propose implementing evidence-based health promotion programming in senior centers that is culturally tailored to the community being served. This initiative may help position senior centers to become centers of wellness, enhancing their appeal to the baby boomer population as it ages.

"Our work has focused on cancer, HIV, and palliative/end-of-life care. In an aging population, oral health issues are critical. This is particularly true among those with health conditions. A major barrier to getting appropriate oral health care for older adults is often financial. Simply put, older adults on fixed incomes may decline to seek oral health care because it represents an out-of-pocket expense that they can ill afford. When an individual has a pre-existing condition, dental treatment may require specialist care, further hindering care access for some populations. Yet we know that serious complications can ensue for dentally underserved older adults, including poor nutrition and social isolation, which can contribute to physical decline. Understanding the needs and identifying the barriers in these populations may help us develop appropriate community-based interventions that could sustain health and enhance their quality of life."

Donna E. Shelley, MD, MPH,
joined NYUCD in 2007 in the newly created position of Director of Interdisciplinary Research and Practice. Dr. Shelley leads a diverse group of faculty from NYUCD and its College of Nursing, as well as healthcare professionals and policy planners from other schools within NYU and elsewhere, in developing healthcare environments that expand access to care and improve the quality of care.