Oral health care in the 21st century: implications for dental and medical education.

The past decade has been turbulent for dental education, marked by debate about the future directions of the curriculum and the profession itself. The bulk of the dental school curriculum is still devoted to tooth restoration or replacement techniques, although the need for these procedures has declined. Some dental educators now advocate an oral physician model as the desired direction for the profession, with expanded training in systemic disease pathophysiology and a practice scope that extends beyond exclusive focus on the teeth and supporting structures. Proponents of this model contend for curriculum time with faculty who desire to maintain a technical focus. The outcome of this curricular tug-of-war has implications for medical education, because many oral health problems now fall into the overlapping educational and patient care environments of physicians, dentists, and other health care providers. Will physicians perceive the new dentist as an encroachment on territory or as a resource to enhance patient care? Within dentistry, the traditions of tooth restoration and prosthodontics shape the profession's culture. Are dental educators ready to reconfigure a curriculum that is deeply intertwined with the professional identity of 150,000 U.S. dentists practicing today? To stimulate thinking about these issues, the authors analyze the responses of dental education to changes in the public's oral health and to calls for curricular reform, propose strategies for modifying the way dentists are prepared for their professional responsibilities, and explore the sociology of change in academic institutions, because elements of dental education targeted for reform are revered components of school culture.

Education of nonscientists about new alcohol research: results of two types of presentations plus 6-month follow-up.

Education of nonscientists by scientists is assumed to be beneficial for enhancing public understanding of the research process and increasing public excitement about science. However, evaluation of audience response to receiving such information has rarely been performed. In particular, the effectiveness of communicating new research on alcohol abuse and alcohol dependence has never been evaluated. Evaluation data in the present study show significant knowledge transfer, belief changes, and participant reports of possible behavioral changes in targeted audiences. These occur when alcohol researchers present basic neuropharmacological concepts and new neurobiological research to audiences consisting primarily of chemical dependency counselors, social workers, criminal justice workers, physicians, nurses, family, clergy, and others interested in alcohol-related problems (defined as "clinicians" and the "reachable public"). Together, these results suggest that it is possible to change the beliefs, knowledge, and behavior of chemical dependency clinicians and the reachable public about alcoholism, its causes, and its treatment.

Implementation of individualized patient education for Hispanic children with asthma.

An educational program known as the Childhood Asthma Project (CAP) was implemented to reduce morbidity among Hispanic children with chronic asthma. Seventy-three children, ages 6-16, participated in 4 program phases: baseline assessment, one-on-one child-centered education, application, and maintenance. During baseline assessment, child and parent asthma beliefs and behaviors were evaluated and used to create educational modules on symptom recognition, peak low meters, medications, and precipitating factors in Spanish and English. Children learned the importance of self-management, practiced using inhalers and peak flow meters and charted peak flow recordings. Videotapes provided peer modeling by showing Hispanic children with asthma performing self-management tasks. During the application phase, patients practiced self-management behaviors at home and reviewed progress with a nurse educator. During maintenance, the success of self-monitoring was reviewed at follow-up appointments. Recommendations for designing health education interventions for Hispanic children are provided.

A case-based learning model in orthodontics.

This report describes a case-based, student-centered instructional model designed to mimic orthodontic problem-solving and decision-making in dental general practice. Groups of about ten junior students meet in a series of one-hour seminars. One week prior to each seminar, a set of diagnostic data is distributed to every student and instructor for advance preparation. A list of questions is included to guide students through the analytical process and they record their diagnosis and treatment plan on a form. At each seminar two preassigned students lead the discussion, and others are randomly selected to answer the programmed questions. Instructors serve as facilitators and evaluators. To ensure consistency of evaluations and feedback, instructors are provided all the expected responses in advance, which they discuss in a pre-seminar meeting. Both students and instructors rated the seminars positively. Students reported significantly higher (p < 0.01) levels of confidence after the seminars for each of seven reasoning skills. This teaching method can be applied to other dental areas to better develop the clinical reasoning skills of future dentists.

Implementation of a physician education intervention. The Childhood Asthma Project.

OBJECTIVES: To increase pediatric residents' knowledge of the Guidelines for the Diagnosis and Management of Asthma (GDMA) developed by the Expert Panel of the National Asthma Education Program and to increase the residents' confidence in their ability to implement these guidelines. Emphasis was placed on the diagnosis and treatment of Hispanic children with asthma, a population at increased risk for morbidity. SETTING: A continuity care clinic located in an urban ambulatory care facility. SUBJECTS: Forty-four pediatric residents: 17 first-year residents, 15 second-year residents, and 12 third-year residents. METHODS: Residents participated in a multicomponent asthma management curriculum that stressed active learning strategies, including the following: focus groups, computer-based testing, lectures, hands-on skill development seminars, role modeling by attending pediatricians, provision of GDMA pocket cards and posters, access to peak flowmeters and spirometry, and an interactive computer-based module. Content focused on pulmonary function testing with spirometry and peak flowmeters, stepwise use of medications, recognition of asthma symptoms and triggers, and cultural considerations that impact asthma management. Pediatric faculty and fellows also participated in a series of asthma seminars to increase the likelihood that faculty would role model the GDMA and provide appropriate feedback to residents. RESULTS: Pediatric residents demonstrated significant increases in knowledge about evaluation of asthma, pulmonary function testing, and clinical management, displayed significantly enhanced levels of confidence, and were enthusiastic about the asthma management curriculum, rating it significantly higher than 15 other content areas in the general pediatric curriculum.

A preliminary study of the effect of eliminating requirements on clinical performance.

This study determined the effect of a clinical program driven by patient needs upon students' productivity, attitudes, and academic performance. A group of eight senior students, whose academic and clinical performance profile replicated that of the rest of the class, were chosen to participate in a year-long non-requirement clinic. The students were expected to attend all clinic sessions, and treat their assigned patients. Their performance was compared to that of classmates in the regular requirement-driven curriculum. The non-requirement group had significantly higher academic achievement and significantly outproduced their classmates. Non-requirement students had no state board failures, versus 17 percent in the regular curriculum, and reported significantly lower stress. This study suggests that predoctoral clinical programs can maintain quality and productivity in the absence of unit requirements.

A problem-based course in dental implantology.

A problem-based predoctoral implantology course was implemented for ten senior dental students at the University of Texas Health Science Center at San Antonio. Students met in small tutorial groups three times a week to analyze patient cases developed for the course. As students explored the patient's problems, they identified areas where their knowledge was deficient, as well as special interests, and prioritized these areas, known as learning issues, into a learning agenda for subsequent study. During unprogrammed free time between tutorials, students researched the learning issues, and came to the next tutorial prepared to discuss what they had learned and in so doing, helped their peers learn the material. The faculty tutor used non-directive questioning to facilitate group problem-solving and promote interaction but did not lecture or give answers. The cases were developed in the "progressive disclosure paperback" format, reflecting the evolving nature of the patient's implant therapy. In conjunction with the PBL tutorials, students performed implant surgery and prosthodontics on a minimum of three patients and provided maintenance therapy on three to four other implant patients. Course evaluation consisted of three elements: (1) weekly peer evaluation by the students using a six item checklist, (2) tutor evaluation, using the same checklist, and (3) an oral examination. The tutor met individually with each student midway through the course and at the conclusion to summarize the peer evaluations and discuss the student's performance, including contributions to group process. Student reaction to this PBL experience was enthusiastically supportive, and student performance exceeded faculty expectations.

The medical school curriculum committee revisited.

Numerous study commissions have contended that departmental territoriality and lack of coordinated planning are stagnating contemporary medical education. As a cure, these commissions have recommended the creation of centralized academic management units empowered to oversee revitalization of the curriculum through a series of reforms, including better definition of graduation competencies, community-based training, interdisciplinary courses, problem-based learning, and modernization of evaluation strategies. To determine the extent to which these recommendations were being adopted, in 1990 the authors sent a questionnaire on curriculum committee functions, current innovation efforts, and future priorities to academic administrators and members of medical school curriculum committees at 143 North American medical schools. Responses were received from administrators (primarily associate deans for academic affairs) at 118 schools and committee members (primarily faculty) at 111 schools. Recommendations for enhancing curriculum committee effectiveness were also elicited. The authors conclude that centralization of curricular management has occurred at very few institutions, and that the commonly mentioned reforms are being adopted at a modest pace. The results are analyzed in light of theories of the institutional change process and strategies for introducing educational innovations into established institutions.

A comparison of two methods for facilitating clinical data integration by medical students.

Two important charting strategies to help students organize patients' data are Weed's problem-oriented medical record (POMR) and Russell's condition diagram (CD). The authors conducted the present study in 1987 to determine whether either was superior for clinical data integration. Sophomore medical students at The University of Texas Medical School at San Antonio indicated whether they preferred the POMR, the CD, or neither. They were then divided into three study groups according to their preferences, with the POMR and CD groups receiving 80 hours of training and the control group receiving only the standard preclinical training. Each student then examined a standardized patient and wrote an open-ended report about the patient's medical problem. After examining a second patient, students were asked to write a structured report providing information about each of ten components of diagnosis. Both the CD and the POMR groups scored numerically higher on the structured type of report than did the controls, but only the CD group scored significantly higher. The CD group also scored higher than did the POMR group on both types of report, but the differences were not statistically significant. This study indicates that the clinical reasoning of medical students can be enhanced by focused training in either the CD or the POMR methods. It suggests that the CD format may be particularly helpful for students with lower academic achievement.

An approach to developing a valid Spanish language translation of a health-status questionnaire.

This article discusses methodological issues confronting health professionals using questionnaires to study health care variables among populations with limited literacy in English, and suggests techniques for minimizing problems that plague questionnaire-based research among these populations. A recent effort to validate a questionnaire for Rheumatoid Arthritis patients in South Texas is used to illustrate pitfalls and potential solutions.

Development and initial validation of a dual-language English-Spanish format for the Arthritis Impact Measurement Scales.

Language, cultural, and educational barriers complicate efforts to validate health status questionnaires that have been translated into Spanish. To overcome these problems, a prototype dual-language format was developed for the Arthritis Impact Measurement Scales. Validity testing with 72 patients diagnosed as having rheumatoid arthritis indicated high levels of test-retest reliability, item-to-scale internal consistency, and construct validity for both Anglo and Hispanic subjects. A technique for developing and pilot-testing a questionnaire written in a regional Spanish dialect is described. Linguistic considerations, questionnaire design, and other applications are discussed in light of the results obtained.

Survey on curriculum committees at U.S. and Canadian medical schools.

A 27-item questionnaire was sent to 144 U.S. and Canadian medical schools to identify prevailing patterns in the organization, philosophy, and function of curriculum committees. Overall, 76 percent responded, with 67 percent of the respondents being school administrators and 33 percent being faculty members. Fifty-one percent rated their school's committee as exerting a significant impact on the educational program over the previous five years. Fifty-six percent of the committees had a routine procedure for course review and used data from multiple sources when conducting curriculum evaluations. The committees that annually received a specific assignment from the dean were the most likely (91 percent) to be rated as having a significant impact, followed by committees that conducted frequent course reviews (66 percent). Thirty-eight percent of the committees were primarily faculty oriented, 29 percent were decidedly administrative in composition, and the remaining committees exhibited a mixture of membership.

A comparison of four simulation and instructional methods for endodontic review.

The effects of four different endodontic self-instructional review formats (slide-tape, latent-image simulation, computer text simulation, and computer-assisted video interactive simulation) on senior clinical endodontic performance are compared. The senior class of 105 students was divided into eight groups of 13-14 academically equivalent students prior to initiating endodontic treatment in the 1985-86 academic year. With the exception of the control group, each participated in a program designed to review principles of endodontic diagnosis and treatment. All clinical endodontic cases were subsequently critiqued by a calibrated panel of two general dentist and one endodontist. Overall, students in the study group made fewer diagnostic errors compared with those in the control group, while the error reduction in clinical treatment was not significantly reduced between the two groups. No significant difference in error reduction was noted between the simulation formats. Student evaluations, as well as comparative developmental expenditures, are discussed.

A four-year longitudinal study of dental student learning styles.

Based on research conducted simultaneously but independently in Europe, Australia, and North America, several new learning style inventories have been developed with well-recognized theoretical foundations and sound psychometric properties. One of the instruments, the Gregorc Learning Style Delineator, was used to study the perceived learning styles of 48 dental students as they proceeded through the four years of the curriculum. Students scored significantly higher on one of four possible learning style dimensions during each year of the curriculum. This dimension, the concrete sequential, is associated with the following learning style characteristics: preference for factual over abstract information, desire for a highly organized learning environment with considerable hands-on opportunity, but free from distractions or ambiguity about learning tasks. Students' preference for the concrete sequential dimension increased significantly as they progressed toward graduation, suggesting that the learning environment of the dental school actually served to reinforce the students' initial predisposition toward the concrete sequential orientation.

A comparison of simulation programs for endodontic review.

Computer-Based Instruction (CBI) has been gaining increasing popularity in the health professions and especially in dental education, but its development is seldom problem-free. This paper describes a longitudinal study of endodontic simulations for senior dental students which employ latent image, computer-assisted video interactive (CAVI), and computer text instruction (CTI). Particular attention is devoted to developmental problems, use of time and manpower, and student performance on and reaction to the pilot test. Preliminary results of the pilot testing demonstrate favorable student performance on the computer-based mode, as well as an enthusiastic acceptance of this format. Future directions and goals of the study are included.

Videotape review: a valuable tool for self-assessment of teaching skills.

This paper describes the components of an instructor improvement program known as VISIT (Videotaping Instruction for Self-Assessment of Instructional Technique). Through the use of videotape recordings of classroom, laboratory or clinical teaching and observation by trained observers, faculty can pinpoint instructional strengths and problem areas, plan refinements and evaluate the impact of these refinements. Ten years of experience with VISIT indicates that post-lecture consultation sessions between the instructor and observer are vital to the success of this activity.