I first met Dr. Joseph Grayden in the fall of 1977 at a meeting with the MN Health Department of Health to talk about a new dental program he developed at Community University Health Care Center (CUHCC) for Native American adolescents who were facing oral health disparities.
He began his dental career just two years earlier, as Dental Director of (CUHCC) under the Clinic leadership of a progressive pediatrician, Jean Smelker, MD , cutting his professional teeth on developing clinical programs to address lack of access to prevention and treatment of oral disease among Native American children in the Phillips Neighborhood of Minneapolis. I have had the privilege of knowing Joe for most of his career at CUHCC as his patient, employee and, like all of his patients, I call him a friend. Thirty two years later, when he announced his retirement from CUHCC and the University of Minnesota, I interviewed Joe and others about Joe for the Phillips Neighborhood paper, The Alley.
Question: What influenced you to begin your dental career at CUHCC?
Joe: When I was a dental student I volunteered at the Gospel Mission in St. Paul treating underserved patients. It was scary at first, but very revealing and left an impression. I was enlisted in the Navy but was on inactive duty. When the Vietnam War ended there were too many enlisted dentists and I was scheduled to go to a remote area of Japan. The Navy wanted to decrease the number of dentists and I saw an ad for the Dental Director position at CUHCC—a one dentist show!
CUHCC was a good place to start. My first boss (Jean Smelker, MD,) helped form my professional philosophy and the mission I had as Dental Director at CUHCC over the years. [Joe said Dr. Smelker’s told him,] “We have to provide not just the ‘community standard of care’ but because we are part of the University of Minnesota, we have to provide a higher level of care than the ‘community standard.’” “We do what is best for the patients and make it work.” Jean’s philosophy became the Dental Clinic’s guiding principle and focused my efforts as an educator, clinician, and Dental Director to implement it into the daily care delivered at the Clinic.
Question: Will you share your history and some of the stories beginning with the early days at CUHCC?
Joe: I started working at CUHCC in 1975 as the Dental Director. CUHCC was receiving Federal funding called C&YC (Children and Youth) Project grants that came directly to the Clinic to treat children within the specific geographical boundary of Phillips Neighborhood. You couldn’t be a patient if you didn’t live in Phillips. The funding came directly to CUHCC and we knew what funding was available. However, because of the funding source, services [medical, mental health and dental] were only available to treat Native American children and youth.
It wasn’t always easy work. We were a community clinic and resources were scarce and the dental needs were great. My biggest goal after the first week working with children from birth to three years of age with early childhood caries [rampant tooth decay] was to find nitrous oxide [also known as laughing gas to patients.] We didn’t have any money for equipment. There was an unused anesthesia machine from the Korean War (still in the box) located in a storage room at the Hospital. I took it home over the weekend and cut off the anesthesia part, leaving only nitrous oxide component. I used it for the next five years. I had to improvise because we were always strapped for money.
[Joe’s colleagues tell other stories of him patching together equipment and maintaining dental equipment throughout his career at CUHCC. Jean Smelker said, “Joe is very handy, even outside of the mouth. Back then we had slow hand piece drills. He was always fixing the old equipment as well as his motorcycles and cars!” Many friends and co-workers remember his living room displaying the latest motorcycle part that he was repairing or painting.]
Between 1975 and 1977, our child patient’s parents and other adults in the Neighborhood organized and influenced the University of Minnesota Hospital and Clinics to develop a prepaid insurance policy that covered care at CUHCC for outpatient services and The University of Minnesota Hospital for inpatient care. Prepaid plans were pretty new at that time. Because of the new funding source I developed the adult dental program that year.
Many of our patients, particularly early on, were Urban Indians. We learned a lot from patients, and we became involved in the community and their lives. They became friends. We were included in their sweat lodges, funerals and birthday parties.
Then by 1977 there was a mix of adults and children at CUHCC and the ethnicity was becoming more diverse as different refugee groups came to Minneapolis. Initially, our largest patient group was Native Americans and around 1975-1976 the Southeast Asian immigrants and refugees came to the Clinic.
Before we built the new clinic where we are now, CUHCC was located in an old three story building without accessible bathrooms or stairs. Everyone chipped in to carry wheel chairs up steps. We had a younger population then so we didn’t have many handicapped patients. CUHCC was a nice place to work. There was a social and professional togetherness and we worked across professional lines to treat patients. We went out to lunch together, had a softball team, and partied together on week-ends. We were single and young and love our work. [Several people interviewed for this story remarked about Joe and the Medical Director lifting patients in wheel chairs up the steep stairway into the clinic, or up another flight of stairs to the third floor bathroom.]
Early on I had a part-time private dental practice in New Hope working Wednesday evenings and Saturdays. I could treat all ages in my own practice. When the Hospital allowed me to rent space at CUHCC for my private patients on evenings and Saturdays, I stopped going to New Hope. After a few years, when CUHCC was part of the University Hospital, they required that all patients (CUHCC’s and my private patients) become part of CUHCC for legal reasons. My private patients could then make appointments during CUHCC’s normal hours. It turned out to be good for the staff as well as the patients. Having a mix of patients from all walks of life and income, kept the staff on a different keel because they were providing high quality care that people of all levels of society would expect. Our philosophy in dental was “no matter who you were [patients] we wanted you to be waiting in the waiting room with people who were poor but whom also came because of the quality of care.
Question: Tell me about your academic relationship with the University and your experience training dental students in the clinic at CUHCC.
Joe: Early on I was a staff member at CUHCC and then had a faculty appointment at University of Minnesota Children’s Hospital and was part of the grand rounds– which was unusual for a dentist at that time. Then I had an appointment in the Pediatric Dental Residency Program with Dr. Kurt King, a Pedodontist who took really good care of children. We [CUHCC Dental] referred children who needed care under general anesthesia to that Clinic. We closely collaborated on our patients’ care.
In 1977 we began to train dental students at CUHCC. My first senior dental student had finished his clinical requirements early at the School of Dentistry and was waiting to take the dental boards. Back then we accepted one student at a time. Many of our dental student trainees became very successful dentists.
In 1978 I became a faculty member in the School of Dentistry spending 50% time teaching clinical dentistry in the Operative Department and 50% time at CUHCC. The amount of time I spent at the School of Dentistry changed a little during the years. Now I am teaching at the School of Dentistry one half day a week.
During the 1980’s if someone was interested in pre-dental school, they could sign up for ‘work-study’ and spend time helping out in the Clinic. One kid, Younas Safa was from Iran. He came here after the Shaw was overthrown. He enrolled in pre-dental classes at the University and every other late afternoon he spent time as my assistant. He is now an Endodontist at USC Dental School (CA.) Another pre-dental student spent afternoons watching extractions and root canals and decided to become a nurse instead of a dentist.
I feel best about the people (students) who came through the work study program, who were interested in dentistry and became happy successful dentists. The dental students rotating through CUHCC had the opportunity to have their eyes opened to real life circumstances. Early on they worked with populations of Native Americans and Vietnamese who were financially depressed and had other things going on in their lives that you wouldn’t understand without treating them and interacting with them on a personal level.” Many other groups of immigrant refugees also came to CUHCC over the years. I think we began seeing Somali patients around 1993.
Question: How did you marry your philosophy of care with training future dentists, while working with such limited resources treating increasing numbers of patients with complex needs?
Joe: The whole clinic firmly believed in minimizing invasive services and there was a focus on prevention. The motto was to, ‘Do as much as you could to prevent disease, and when you couldn’t prevent, treat with the least invasive services.’ Dental Residents [dentists in graduate training programs] received training in minimum invasive dentistry. Being in an area where patients had little money for care, and the Clinic had little money we had to be very careful with our treatment plans. We were challenged to come up with options that were more affordable and of high quality.
Question: Can you give me an example of your early preventive orientation?
Joe: CUHCC was a public health clinic that was able to have an active dental hygiene department. We initially had two dental hygienists. At other public health clinics at that time, patients could come in once a year for teeth cleaning appointments. At CUHCC, patients who needed four appointments a year to maintain the health of their gums were scheduled with a hygiene hygienist. The hygienists were treating periodontal patients [those with gum disease] to maintain their teeth rather than having the dentists extract teeth. The clinic also performed root canals and restored teeth to function rather than extracting them. We were ‘doing what was best for the patients and making it work—our mission.’
Question: When I interview Dr. Jean Smelker, among the many compliments and early stories, told me about your finger problem. I think it is a good example of the holistic nature of services and the camaraderie at CUHCC. Will you share the story?
Joe: Jean Smelker was a very holistic kind of physician. She is very bright and ahead of her time in many ways. She was big with hypnosis. I had a wart on my finger that bothered me when I practiced dentistry. I had been treating it [wart] over a long period of time at a dermatology clinic. They tried cutting it off, then burning it, then freezing it and I still couldn’t get rid of it. Jean hypnotized me and taught me self hypnosis; within a week it was gone. When Jean was at CUHCC, medical care was good.”
Question: What else do you remember about the early days at CUHCC?
Joe: In 1991, physicians and dentists at CUHCC collaborated in patient care. John Raines, an Internal Medicine doctor made house rounds with patients that were too ill or bedridden. I went with him on house rounds and would go to homes of bedridden patients to provide dental care using portable equipment.
Question: What other changes did you experience at CUHCC over the 34 years you were Dental Director?
Joe: I have mentioned a few changes but there were several transitions that effected who we could see as patients, and the effort needed to get resources to provide high quality care to the ever increasing number of people with complex care needs. Funding sources sometimes defined who we could treat as in the example of the C&Y grants. When they became Block Grants, we had to compete with the rest of the State and there was a pecking order to get the funding. We weren’t always at the top of the order.
Also, who we reported to at the University made a difference too. People like Russ Farrell (1970’s and 1980’s) who was CUHCC’s link to UMN when we were linked to the Academic Health Center (AHC), was passionate about the mission and saw to it that we were supported.
We are always scrambling to write grants to patch together funding. Other changes occurred when additional groups of refugees immigrated to Minnesota, many having years of unmet treatment needs, the care requirements became much more complex. Over time, our staff became more diverse reflecting the patient groups giving us a better opportunity to learn about different cultures and their health-related circumstances.
The University of Minnesota Hospital was required to provide charity care so if we ran over budget, sometimes they had to absorb some of the losses. Mostly when we ran short of money, we cut positions. After Jean Smelker left CUHCC, Amos Deinard became Clinic Director and the the Minnesota Medical Foundation helped CUHCC seek money for the new Clinic which was built in 1991.
When The University of Minnesota Hospital merged with Fairview Hospital, CUHCC’s affiliation ended along with their financial support from the Hospital. CUHCC stayed with the University and we moved back under the administrative umbrella of the Academic Health Center (AHC). Although we no longer had the support of the Hospital, we increasingly saw more patients with complex needs, so there was a lot of effort at CUHCC to hustle funding through multiple grants. We became a Federally Qualified Health Care Center look-alike which meant that we received Federal money to treat Medicaid eligible patients. Later around 2001, when the Clinic became a full FQHC clinic there were additional monies that helped to pay for some of the costs of treating uninsured patients. This grant source required that we meet additional federal guidelines.
Both Joe and Dr. Smelker talked about the importance of key people at the University of Minnesota early in CUHCC’s history who supported CUHCC’s mission. According to Dr. Smelker, Lyle French, VP of the Health Sciences was committed to the concept of ‘communiversity’ and was instrumental in keeping the University in the community as a public service. They both talked about the importance of Russ Farrell, an administrator in the Academic Health Center who was administratively responsible for CUHCC. Joe said of Russ: “There were positive feelings about the importance of oral health from the very top to the bottom of the organization [University of Minnesota. That has not always the case. Russ was always coming to CUHCC and his involvement was historically important for CUHCC.”
Thank you, Joe, for your friendship, the high quality and caring service to patients at CUHCC, preparing future dentists to spare teeth, and for shaping CUHCC’s Dental Clinic as a true ‘communiversity.’
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