Reforming Dental Health Professions Education

1. Reforming Dental Health Professions Education Dom DePaola and Hal Slavkin Santa Fe Group

2. What we do know: • Disease patterns are changing • Knowledge is exploding • Demographics are changing • Health disparities are prevalent • Mouth is connected to the body • A new science of medicine is here! • Current dental practice is self-limited • Dentistry is left out of primary health care • Dental students cannot process current curriculum content • 10. Costs of education and health care are increasing • 11. A new health care system is here!

3. What we do know: 12. Support for education is diminishing 13. Extramural focus is limited but improving 14. Competencies for clinical practice need to be redefined 15. Faculty recruitment and development is necessary 16. Research and the scientific method are not integral to the fabric of education 17. Dental manpower is diminishing 18. Science transfer to practice is too slow 19. Dental education remains inflexible 20. Allied Health Professions need expanded opportunities

4. There is a huge chasm and disconnect between the expanding knowledge base, between what is taught, how it is taught, and the clinical practice of dental medicine.

5. …Evidence into Practice The gap in science transfer to patient care isrooted in two fragmented and separate health care systems– the consequences of which are enormous in terms of: + professional isolation + health care costs + reimbursement policies and finances + health outcomes + health disparities + access to care and licensing regulations + educational preparation + practice characteristics Pearson and Douglass, St. Luke’s Health Initiatives, June 2003

6. The dental education community has responded to the winds of change with some growth and little change! Tedesco, J.Dent.Educ. 1995, 59, 97

7. Survey of Dental Education • Increased use of computers and web-based learning • Enhancement of competency evaluation methods • Creation of early patient care experiences, curriculum decompression • Increased community-based care • Increased use of evidence-based dentistry Kassebaum et al, J Dent Educ, 2004, 68(9), 914

8. Unifying Vision of Dental Education Dental education is a continuum that leads from predoctoral science and clinical education, moves into professional training in the clinical, biomedical, and behavioral sciences, and then extends on into life-long learning in dentistry. The notion of an educational continuum is fundamental and profound.

9. Dental Science Education Preferred Model Reductive Science PhD DDS, PhD DDS/CE Basic Clinical Translational Research Investigation Research Integrative Sciences: biomedical; population; behavioral Adapted from M.Cox, Harvard Medical School, 2003

10. The unifying vision will also result in: • Practitioners trained to meet the oral health needs of the population by providing them foundational knowledge, critical thinking, problem-solving, teaching skills and attitudes for success. • A new generation of scientists trained to advance the oral health of the population. • A new generation of adaptable dental educators who can respond to an ever-changing reality. • Students and practitioners who are scientifically literate and embrace life-long learning. • Enhanced clinical competence and performance in clinical decision making.

11. Dental Education Reform: • End the “silo” approach to education • 2. Create an efficient pathway to link competencies to subject matter and learning experiences, which, in turn, are linked to evaluations that measure performance of these competencies Hendricson & Cohen, Acad Med 2001, 76, 1181

12. Clinical Paradigm Change Patient Assessment by Primary Health Care Team (physicians, dentists, other health care professionals) Risk Assessment Diagnosis Referral to specific clinical entities Patient returns to team Discharge order(s) Recall

13. Education Implications of Contemporary Oral Health: * Some of the most pressing issues are no longer purely dental in nature * Provision of oral health care is increasingly intertwined with public health policy, resource allocation, and care delivery/access issues * “Splendid isolation” of dental practitioner is in question * The perception of oral health as an integrated component of overall wellness emphasizes the role of dentists as oral physician. Hendricson & Cohen, Acad Med 2001, 76, 1181

14. It is time for a “creative revolution” to sweep across the profession to bring it into the 21st century led by a contemporary, vibrant and exciting educational enterprise!

15. Recent Reports on Dental Education Reform • Pew Center’s National Dental Education Program • Institute of Medicine Report, 1995 • Dental Education at the Crossroads • American Dental Association’s Future of Dentistry • 2000 Surgeon General’s Report Oral Health in America • Surgeon General’s 2003 National Call to Action

16. Trends in Dental Education + Community-based education + Replacement of licensure exams with a mandatory post-graduate year of study + Competency-based education and accreditation + Expanding teaching of evidence-based dental medicine + Renewed emphasis on prevention strategies including: * risk assessment * behavioral interventions * medical management + Establishment of Interdisciplinary teams - clinical collaborations + Virtual dental education Pearson and Douglass 2003

17. …Evidence into Practice Unfortunately: * The great majority of schools continue to use “lock- step: approach to basic and clinic science instruction, with little integration of science underpinnings at the clinical level and with continuing metastatic, irregular additions to the curriculum. * It continues to be easier to base a curriculum on what was necessary to teach rather than what will be necessary to learn in the future! DePaola, 1990

18. Assumptions • Reform of oral health education is critical to enhancing the quality of health and well-being for all people in the United States. • Health professions education environments are not interdisciplinary, whereas health care clinical practice and clinical research require explicit interdisciplinary efforts. • No one model of template for dental education will suffice for all dental schools. • There must be a unifying vision of what dental education “could be” and what a 21st century practitioner “could be”. • Adequate resources must be aligned to realize the vision of dental education. • A common language and core competencies across health professions have not as yet been achieved. • Competencies must be well-defined and renewed thru a lifetime of professional activities.

19. Assumptions • Evidence-based core competencies should be established across all health professions and integrated with clinical care services. • 9. Dental education must enable individuals to learn, to re-invent and to attain contemporary competencies over a lifetime. • 10. The collaborative role of allied health professionals must be expanded significantly, holding open the possibility of developing pediatric oral health therapists, among other new “reconfigurations” of providers. • 11. Integrative biomedical, population, behavioral, social and economic sciences must be incorporated into the curriculum at every level. • There must be regular assessment of curricula and pedagogical outcomes and continual documentation of clinical skills • Scientific discovery coupled with translating science and technology into clinical practice must be a core value of dental education.

20. Assumptions • 14. Critical thinking, problem-solving, information management, leadership and teamwork, and life-long learning must be integral in all dental education models. • 15. Humanism, professionalism and communication skills must underpin the education process. • 16. Innovation, creativity and the nurturing of ideas must permeate dental education and clinical practice. • Itwill take a village to reform dental education, including individual faculty members, organized dentistry, industry leaders, funding agencies, insurers, patient advocates, the media, public health advocates and practitioners, leaders from research, education and government, and the public. • This conference cannot be the end, it MUST be the beginning. We must take concrete steps and “walk our talk;” we must begin and sustain the journey.

21. The lack of an umbilicus to the dental school and/or hospital is a major contributor to the dentists’ professional isolation and the slow transfer of contemporary science to patient care!

22. Reform Agenda  Competency-based assessment ü Decompress the curriculum through elimination ü Increase collaborations between dentistry and other health professions ü Feature curricular emphasis on dental/medical interactions ü Redirect basic sciences toward pathophysiology using PBL or other appropriate education techniques ü Expose students to patients from first through last days of the curriculum ü Revitalize the science underlying clinical decision-making via evidence-based approaches ü Organize group practice teams to promote continuity and expand peer teaching ü Increase community-based clinics as training sites ü Include a clinical experience that replicates the comprehensive care environment for the general practitioner ü Utilize web-based and computer-based technology for enriched learning ü Redirect dental school clinics to serve oral health needs of the public Hendricson & Cohen, Acad Med 2001, 76, 1181

23. Dental Education Reform: Dental schools should aspire to become “learning organizations” where: There is a high capacity for implementing change There is comfort in the processes to support innovation Hendricson & Cohen, Acad Med 2001, 76, 1181

24. Why is reform needed now? * A critical need to address the problems in the current system of dental education, including: • Ø   inability to train practitioners to care for all patients, including the disadvantaged • Ø   inability to nurture the critical mass of critical thinkers and problem-solvers for research and academia • Ø   inability to train socially responsible practitioners • Ø   lack of diversity in students, educators and practitioners • Ø lack of expertise in specific content areas; for example, pediatric oral health care; care for special populations; general health; cultural competency; experience with the underserved; social context with responsibility; behavior and communication skills • Øthe continuing focus on oral health and technical skills to the neglect of overall health and the social/behavioral focus needed to address disparities • Ølack of interdisciplinary perspective/practice • lack of ability to relate to and address the overall health of the patient.

25. Why is reform needed now? *A need to reduce costs of education. * A need to integrate biology into the fabric of dental education and clinical practice. * A need to resonate with the mission of the university and/or academic health center. * A need to expand access to education and clinical care. * A need for leadership and citizenship development. * A need to integrate effective and efficient management, staffing, and clinical productivity.