In 1971–1972, a World Health Organization commission assessed health professions education throughout the world, including the United States. The commission concluded that education is inextricably interwoven with the health service system, and when questions arise about the delivery of service, questions about the training of health care providers follow soon after.1 And, indeed, in the 30 years since that prophetic report, a torrent of questions has been unleashed in the United States about the way medical care is provided for the public, leading to a still-evolving reconfiguration of the health care landscape and, as predicted, scrutiny of the way health care providers are prepared for their professional roles in society.2–5 In this article, we focus on dentistry, a profession that has similar public service roles and shares a common biomedical science foundation with medicine, but which has been differentiated into different pathways for education, licensure, and scope of practice for a variety of complex historical, economic, political, and philosophical reasons. (For more about our goals for this article, see the later section entitled “Purpose of This Article.”)
WINDS OF CHANGE
Winston Churchill said that “the winds of change are blowing and we lean into them with equal measures of anticipation and dread” to capture the conflicting emotions that arise when established institutions and methods are questioned.6 The winds of change have been blowing since the 1980s in U.S. health professions education. The 1984 report of the Association of American Medical Colleges (AAMC) panel on the general professional education of the physician (the “GPEP report”) and the reports of the Pew Health Professions Commission a decade later were catalysts for curricular introspection in medical schools and other health professions schools.7–9
The dental education community embarked on an analysis of its own curricular health approximately ten years ago. This introspection led to the 1995 Institute of Medicine (IOM) report entitled Dental Education at the Crossroads: Challenges and Change, which proposed reform of curriculum content and modernization of teaching and learning methods.10 Both before and after that IOM study, there was agitation for change among elements of the dental school faculty and administration. Catalysts for change in dental education include projections of faculty shortages counter-balanced by projections of increased public need for oral health providers and services, particularly in large underserved populations; desire at the administrative level and among some faculty to play a more proactive public health role by extending student education and patient care services into the community; advances in genetics and molecular biology with implications for patient care and thus for curriculum content; faculty desire to upgrade the scientific basis of the clinical curriculum; and resource-driven evaluation of long-standing educational and patient care practices in the dental school clinic that may no longer be educationally or economically viable.
At the core of the debate over future directions is what has been called the “surreal duality” of dental education and the profession.11 At one end of the spectrum, a large portion of the curriculum is devoted to mechanical techniques taught and evaluated in fine-grain detail, for example, placing a class II amalgam restoration or constructing a removable partial denture. At the other end, dentists are expected to be accomplished diagnosticians capable of assessing and managing a multitude of oral pathologies (i.e., oral physicians, with expanded focus beyond the teeth and supporting structures) and knowledgeable about sophisticated biomedical science concepts—for example, the roles of carcinogens such as benz-pyrene and tobacco-specific nitrosamines in the production of DNA adducts such as 06 methyl guanine, which interfere with DNA replication; or the genotypes of interleukin-1 that are associated with adult periodontal disease. The biomedical science component of this duality has been brought into sharp focus by two recent events: the Human Genome Project12 and the Surgeon General's report on the oral health of America.13 This duality has created tension within dental schools as proponents of an expanded biomedical emphasis and a broader concept of the dentist's health care role aggressively contend for curriculum time with faculty who desire to maintain the traditional technical focus (e.g., the traditional tooth-doctor role). Efforts to accommodate both components of this duality have produced excessively dense curricula at most dental schools.
PURPOSE OF THIS ARTICLE
A preliminary version of this article was developed by invitation for the 75th Anniversary Leadership Summit Conference of the American Association of Dental Schools (AADS), conducted in October 1998. Fifty dental school deans participated in that meeting and were accompanied by the chancellors of their parent academic health science centers. The purposes of the conference were to stimulate thinking about the future directions of dental education within the broader purview of health professions education and to assess the role of the dental school within the academic health center. The early version of the present article was read by the summit conference participants and debated in small-group sessions. Based on encouragement and feedback from conference participants, a revised manuscript was made available to the dental education community through the AADS Web site in December 1998. A further modified version, incorporating feedback from individuals who had read the on-line version, was published in the conference proceedings, Leadership for the Future: The Dental School in the University, in the summer of 1999.14 Additional feedback from a variety of individuals and the authors' own critical reflections led to the present version. The authors are education specialists who are not dentists but who have more than 50 years of combined experience as consultants for two thirds of the dental schools in North America. We also have worked for more than 100 medical, pharmacy, nursing, and allied health schools, residency programs, and medical specialty associations.
Our goal for this article is to stimulate dialog among medical and dental educators about the scope, structure, and content of the training provided for dentists as we enter the 21st century. To accomplish this goal, we first review the publics' evolving oral health status since World War II as an indicator of curriculum priority and content. In the second section, we consider the extent to which dental schools responded to the changes in oral health over the past 50 years and to calls for curricular reform. In the third section, we examine three institutional strategies we believe can make a difference in the way dentists are prepared for their professional responsibilities: (1) developing a curriculum based on competency-based techniques, (2) blending the education of oral health specialists into the broader system of health professions education, and (3) expanding public health and prevention training for dental school graduates. We used these three strategies to create a description of a prototype 21st-century dental school curriculum, which appears in the appendices. We hope this prototype will stimulate the discussion and establishment of alternative models for the oral health component of health professions education. In the fourth section, we explore the sociology of change in medical and dental schools. To orient medical educators to the dental school environment, Table 1 provides a synopsis of some of the principal similarities and differences between educational programs leading to the MD and DDS/DMD degrees.
I: ORAL HEALTH IN AMERICA — 1945 TO 2000: IMPLICATIONS FOR CURRICULUM PRIORITIES
It is often stated that oral disease is the most common disease of mankind and quite possibly the one disease that all humans have in common, yet the parameters of what constitutes oral health, and conversely oral disease, are often vaguely defined. What is oral health? Mouradian defines oral health as “encompassing all the immunologic, sensory, neuromuscular and structural functions of the mouth and craniofacial complex. Oral health influences and is related to nutrition and growth, pulmonary health, speech production, communication, self-image and societal functioning.”15 Mouradian also proposes that oral health is intertwined with “all aspects of a child's developmental processes, genetic potential and environmental circumstances.”
In the years immediately following World War II in the United States, dental caries and periodontal disease were widespread, with high percentages of patients experiencing rampant caries, periapical abscesses, and advanced periodontitis, all of which produced a high degree of endentulism. Because physical removal of caries and tooth extraction were the primary treatments available, the primary foci of the dental school curriculum were teaching students to extract teeth, physically remove decay, replace the excavated tooth structure with various materials, including gold, stainless steel, and amalgam, and create prosthetic devices to replace missing teeth.
However, several decades of research into the biologic causes and mechanisms of dental infection, leading to enhanced preventive and therapeutic regimens; the widespread use of fluoride as a prophylactic mechanism; and aggressive patient education have substantially reduced tooth loss and the incidence of caries in child, adult, and geriatric age groups.16 Further progress in prevention and therapy is anticipated as we expand our understanding of the genetic basis of oral diseases and from advances in cell and molecular biology, immunology, and pharmacology. As we enter the 21st century, oral health is better than ever for the majority of Americans. The remarkable reduction in oral disease and accompanying sequelae is one of the more dramatic success stories in U.S. public health and one that should be a source of considerable pride for the dental profession. However, significant challenges remain, especially at opposite ends of the age spectrum—for children and the elderly—and in a large and still-growing underserved population composed primarily of ethnic minority groups and the economically disadvantaged.
Oral Health Problems in 2001
A curriculum for health care professionals-in-training should prepare entry-level practitioners to provide prevention, assessment, and treatment services for the most pressing current and predictable future health care problems of society. What does the oral health of Americans in 2001 tell us about curricular directions for dental school? Large segments of the public still have significant oral health care needs in a variety of areas (discussed in more detail in later paragraphs): chronic facial pain and impaired jaw-joint function, craniofacial birth defects, craniofacial trauma including physical violence inflicted on children, dental caries and associated health problems—particularly among children, head and neck cancers, periodontitis, tobacco-related disease, and the evolving oral health needs of our rapidly expanded elderly population.
Three other factors will strongly influence dental care and dental education in the 21st century: (1) research exploring potential interrelationships among oral disease and disorders classically defined as medical problems, including diabetes, perinatal problems, and cardiovascular disease; (2) the increasingly multicultural fabric of our society; and (3) access-to-care issues, particularly for the young, the elderly, and the economically disadvantaged. Of course, there are many other oral health problems—including oral candidiasis, particularly as an early sign of HIV infection; herpesvirus infections, as related to bidirectional genital—oral herpes and associated sexually transmitted diseases; numerous anomalies of cranial bones and teeth, and Sjögren's syndrome—but they are not discussed here because they are less frequently observed by the dental practitioner.
Chronic facial pain and impaired jaw-joint function. More than 20% of adults experience chronic facial pain, the effects of which can profoundly effect quality of life. Facial pain may emanate from tooth-related infections or mucosal sores and irritations, and also includes burning sensations in the mouth, temporomandibular joint pain, and generalized pain across the face or cheek. More than ten million Americans experience pain and dysfunction related to the temporomandibular joint, including musculature pain and difficulty opening the mouth, with accompanying problems in chewing, headaches, and pain emanating from the ear. Women report both generalized facial pain and temporomandibular joint pain at substantially higher rates than men do.17,18 A number of research centers around the world are now investigating the frequently-observed co-existence of temporomandibular pain disorders, fibromyalgia, and chronic fatigue syndrome, and dentists are involved on many of these research teams.19
Craniofacial birth defects. More than 150,000 infants are born each year in the United States with congenital malformations, and these conditions can affect facial appearance, speech, and various quality-of-life indices, including self-esteem. Defects affecting the orofacial complex, including cleft lip and palate, are the most common, resulting in more than one billion dollars of expenditures annually for the extensive surgical, medical, and rehabilitative interventions needed to repair these defects, and for prosthetic devices.20 Maternal cigarette smoking has been identified as a significant risk factor for oral clefts.21
Craniofacial trauma. There are more than 20 million visits per year to emergency departments for craniofacial trauma involving injuries to the jaw, dentition, or soft tissues of the oral cavity. An additional six million head and neck injuries annually are treated by dentists in their offices.22 Overall, 25% of all children and adults will experience a traumatic injury to one or more anterior teeth.23 In the National Health Care Survey of Emergency Rooms, violence (physical assaults) and falls each accounted for 31% of visits related to head and face injuries. Two thirds of the physical abuse experienced by children is head and neck trauma.24,25
Dental caries and associated health problems. In spite of the dramatic reduction in caries in the overall population since World War II, the most common chronic childhood disease is still dental caries, which afflicts 57 million of our children, making it five times more common than asthma and one of the most common causes of missed school days. The incidence of caries, 50% in mid-childhood, has remained the same for a number of years despite the availability of recognized preventive measures.26 One in four children in the United States live in conditions of poverty normally associated with an impoverished developing nation rather than an industrial power; not surprisingly, the incidence of oral disease is disproportionately represented among children from low-income households.27 Seventy-five percent of all childhood dental problems occur in 25% of children, primarily those of low-income and minority status.28 One third of all Head Start preschoolers and 50% of Native American children have early childhood caries (ECC), which is clinically correlated with compromised oral function, poor nutrition, and diminished height and weight attainment.29 In all children, regardless of ethnicity and economic situation, dental caries is typically a comorbid condition with other indicators of poor health status, and in particular is strongly associated with nutritional deficiencies that underlie a number of childhood health problems.15 Oral health is also intertwined with childhood diseases, including asthma and cystic fibrosis. Asthmatic children have more decay affecting permanent teeth, poorer periodontal status, and more loss of tooth surface than do their non-asthmatic peers.30,31 The higher incidence of caries in children with restricted airway disease is thought to be associated with their use of beta-2 agonists, which contribute to reduced salivary flow, as well as to mouth breathing and esophageal reflux, which are common in this population. The poor oral health of children with chronic respiratory and gastrointestinal infections has also been associated with long-term use of liquid medications containing carbohydrates and sugar.32
Head and neck cancers. One American per hour dies from oral, pharyngeal, or nasopharyngeal cancer, which is now the sixth most common form of cancer, behind lung, stomach, breast, colon, and rectum/cervix cancers.33 In 1997 in the United States, there were 21,000 new cases of oral cancer among men, with 5,600 deaths, and approximately 10,000 new cases and 2,800 deaths among women. The overall five-year survival rate for people with oral and pharyngeal cancers is only 52%, which is worse than the rates associated with cancers of the prostate, rectum, uterus, colon, breast, bladder, and larynx in both black and whites.34 The number of deaths from oral cancer has increased year by year over the past 25 years.33,35 Tobacco use, heavy alcohol consumption, and poor diet are the primary etiologic factors for more than 90% of head and neck cancers, with tobacco use alone representing 80% of the risk factors.36,37
Periodontal disease. Sixty percent of adults in the United States will have periodontal disease in their lifetimes, and it is a significant contributing factor to the loss of more than 12 teeth that the average American experiences by the age of 50. Aside from caries, periodontal infection is the most common reason for dental visits, and in advanced forms can require extended, unpleasant, and costly therapy, including surgical interventions.
There is a strong association between smoking and periodontal disease. Approximately 50% of periodontitis cases are caused by smoking, and the outcomes of periodontal therapy are adversely affected by smoking.36 A recent longitudinal study of 900 male and female teenagers found that smokers are nearly three times as likely as their nonsmoking peers to have periodontitis in their mid-20s and resulting loss of periodontal attachment, which is the bony and soft-tissue support for the teeth.38 In addition, the preponderance of research has established an association between diabetes, either type 1 or type 2, and periodontal diseases to the extent that periodontitis has been called the “sixth complication of diabetes.”39 People with diabetes experience gingival inflammation, loss of periodontal ligament attachment, abscesses, alveolar bone loss, and tooth loss more frequently and with greater severity than do those in non-diabetic populations. Sixteen million people in the United States have type 1 or type 2 diabetes, and the medical complications of this disease represent the seventh leading cause of death.40,41 There has been considerable research to determine whether periodontal infection effects glycemic control. The results suggest a relationship, but are not conclusive.
Tobacco-related diseases. Tobacco use is the single most preventable source of death and disability in modern society. Fifty percent of regular cigarette smokers will die from a tobacco-related disease, and one third of these smokers will die early, losing on average 20 years of life. Worldwide, there are now four million tobacco-related deaths annually, and such deaths are projected to increase to more than eight million by 2020, when tobacco-related deaths will account for one in six deaths from all causes. In the United States, there are 500,000 deaths associated with tobacco use each year. Thirty percent of all cancer is linked to tobacco use.42,43 Tobacco is also a significant risk factor for other diseases of the mouth: ulcers, periodontal disease, cleft lip and palate, and caries, and tobacco use delays healing of wounds.36,43
Odor, tooth staining, poor hygiene, and telltale oral disease make tobacco use obvious to dentists and dental hygienists. The typical dental appointment is considerably longer than modern medical appointments, affording opportunity for dentist—patient discussion of tobacco use and its consequences. However, Tomar reported that only 24% of current smokers received advice from their dentists to quit using tobacco.44 Dolan found that just 30% of dentists offered tobacco-use cessation services to patients, and fewer than one in five felt they were adequately trained to help their patients stop smoking.45 Dentists do not provide tobacco-use cessation services for three reasons: they do not perceive such services to be part of their responsibility, they fear that they may alienate patients, and they lack confidence in their ability to provide such assistance to their patients. In contrast, dental patients now expect their dentists to help them stop smoking, and the dental or dental hygiene appointment may provide a powerful opportunity for cessation education, particularly when precancerous lesions and other undesirable sequelae of smoking are evident in the patient's mouth.46 Yet, in 1999, only 11 U.S. dental schools provided instruction in tobacco-use cessation or prevention techniques.47
Changing oral health of the elderly population. Americans 65 years old and older are the fastest-growing segment of our population. In 1900, the median age in the United States was 23 years, and only 4% of Americans were 65 years of age or older. By 1995, 13% of the population were aged 65 or older, and by 2050, more than 20% of the population will be 65 years old or older.48 Further, by the year 2020, it is projected that 60% of hospital admissions and one third of all medical outpatient practice will be devoted to geriatric patients.
Estimates of geriatric patients currently in dental practices range from 25% to 30%. Because of technologic advances in diagnosis and treatment, many people who in the past would have succumbed at earlier ages to cancer, cardiopulmonary disease, immunologic disorders, and trauma are living longer, but with an array of chronic medical problems complicated by physical limitations, mental disabilities, and polypharmacy. Because senior citizens are losing fewer teeth prematurely, they conversely will be more at risk for caries and periodontal disease later in life, leading to less reliance on the full denture and greater need for other forms of oral health care to address the needs of the partially edentulous patient.49 As the over-65 population grows, there will be a concurrent growth in the number of home-bound frail elderly and those living in long-term care facilities. More than 40% of the elderly already reside in long-term facilities at some point in their lives.50 These individuals will pose a new challenge for dentists and other health care professionals.
A number of studies have documented a high incidence of oral disease among home-bound, nursing home, and hospice patients, with almost 20% requiring emergency dental care.13 Kiyak and McIntyre found that 70% of patients in long-term care facilities had unacceptably poor oral hygiene.51,52 Nurses and nursing auxiliaries in long-term care facilities are not trained to provide oral hygiene care or to recognize problems, which is complicated by the fact that oral hygiene for the elderly is considered an unpleasant task and thus may be neglected.
Oral Disease—Systemic Disease Relationships
The mouth is a productive incubator for bacteria, viruses, parasites, and fungi. More than 500 bacterial strains have been identified in the oral cavity, and 150 strains have been identified from infections of tooth pulp.53 In spite of immunologic mechanisms, pathogens from the mouth can enter the bloodstream or the lymphatic system. Researchers are now exploring possible relationships between oral infections and other medical disorders. In addition to the periodontal infection—diabetes relationship, the two potential oral—systemic relationships that have received the most attention are those in perinatal morbidity and cardiovascular disease.
Perinatal morbidity. Infant mortality has decreased over the past 20 years, but the incidence of low-birth-weight infants has not declined despite emphasis on prenatal care. Approximately four million low-birth-weight infants are born annually, both preterm and full-term, resulting in a significant level of perinatal morbidity, untold emotional distress among family members, and resource expenditures in the billions of dollars. Preterm birth and/or low birth weight is the principal factor in 60% of infant mortality.54 Oral infection has been proposed as a potential cause of prematurity or low birth weight, perhaps as a sequela of toxins form oral pathogens that reach the placenta and disrupt fetal growth and development. Several case—control investigations indicate that pregnant women who have severe periodontal disease are at higher risk to deliver preterm and/or low-birth-weight newborns. In one of the few studies to control for causal factors such as smoking, alcohol use, nutrition, age, ethnicity, and gastrointestinal tract infection, Offenbacher found a sevenfold increase in risk for mothers with periodontal disease.55,56 However, more controlled studies are needed before definitive conclusions can be developed.
Cardiovascular disease. For years, evidence from uncontrolled studies, retrospective reviews of national health databases, case reports, and anecdotal evidence have indicated that the risks of heart disease may be substantially higher for persons who have periodontal disease.57 Research interest has increased in the past decade; for example, the National Heart, Lung and Blood Institute of the National Institutes of Health is sponsoring studies of the role played by biofilm-forming bacteria (which colonize the mouth) in the release of pro-inflammatory mediators by white blood cells, which may, in turn, trigger stroke and heart disease. In studies that adjusted for risk factors such as smoking, hypertension, obesity, diabetes, elevated cholesterol, and family history, there have been consistent findings that patients with periodontal disease are 1.5 to 2.0 times more likely to develop cardiovascular disease or experience a stroke.58–60 However, a study that monitored 8,032 subjects in the National Health and Nutrition Examination Survey Epidemiological Follow-up Study for 20 years did not identify an independent relationship between periodontal disease and coronary heart disease.61 A number of investigations of the relationship of oral infection to heart disease are in progress around the world, and understanding of that relationship should improve in the next few years.
Multicultural Environment for Oral Health Care
Dentists in the 21st century will serve the oral health needs of an increasingly multicultural public as the percentages of Hispanic, African-American, Asian, and other patients continue to grow in relation to the Anglo (i.e., non-Hispanic Caucasian) population. Overall, the growth rate of the U.S. population had slowed to an all-time low of 10% growth per decade in the 1990s, compared with 19% in the baby boomer period of 1946–1966, 15% from 1900 to 1940; and 30% per decade in the 1800s. The net increase in the U.S. population since 1990 was 19 million, and 67% of this growth was accounted for by minority populations.48 By 2020, if current birth and mortality rates continue, 40% of the children and adolescents in the United States will be members of minority groups, versus approximately 25% in 1980.62,63
Accordingly, many patients will enter the dental office with different health care beliefs, motivations, and expectations than those held by previous generations of patients, and providers will experience differences in disease prevalences as the patient pool diversifies. For example, African Americans experience nearly twice the morbidity and mortality from oral cancer that Anglos do.16,64 A variety of studies have revealed that members of minority populations experience greater risk for overall health morbidity, including oral disease, due to language barriers, lack of geographic proximity to health care facilities, lack of reliable transportation, lack of health insurance, and particular culturally-based beliefs about health and illness.65–67 The economic status of U.S. families is also projected to decline over the next 50 years. Murdock estimates that the average household income in 2050 will be $2,000 less than that in 1990 (measured in 1990 constant dollars). Further, the current income differences between Anglo, African-American, and Hispanic households (Anglo = $39,000; African-American = $23,500; Hispanic = $25,000) will continue to spread over the next 50 years.48 Disparities in dental health between the Anglo population and elements of the Hispanic, African-American, and Native American populations and between the economically advantaged and disadvantaged, without regard to ethnicity, parallel the disparities evident in other areas of medical care.13
Access to Dental Care
Overall, in the early 1990s, 9% of the U.S. population, or 22 million people, reported unmet dental care needs in a study by the Project Hope Center for Health Affairs, based on the 1994 National Access to Care Survey by The Robert Wood Johnson Foundation.68 Eight million more people reported unmet oral health needs than reported medical care needs that were not met. Seventy-four percent of the individuals reporting unmet dental care needs considered their problems to be serious. Ethnicity and socioeconomic status were strongly associated with the lack of dental care. Twice as many African Americans (15%) reported unmet oral health needs as did Caucasians (7.4%). Among those who wanted dental care but did not get it, 72% reported it was because they could not afford it, had no insurance, or could not find a dentist who would accept their insurance.
In the United States, utilization of oral health care services and the incidence of oral disease are strongly linked to dental insurance coverage, particularly for children. Sixty percent of children have medical insurance coverage through their parents' workplace health plans, but only 30% have dental insurance through their parents' employers.69,70 Only 20% of Medicaid-eligible children receive any type of dental care, and only a handful of oral health care services that might benefit children are eligible for Medicare reimbursement.28 Parents report that dental needs are the most common of all unmet health care needs for their children.71
For adults, dental plans are available from about 60% of employers, and the majority of these plans are fee-for service. About 30% of employees receive dental benefits from preferred provider or health maintenance organizations. The elderly typically lose dental insurance benefits when they retire; thus dental care is primarily an out-of-pocket expense for senior citizens, which may become a significant public health issue as more and more of our elderly live into their 80s and beyond with their dentition largely intact. Finally, a critical oral health access issue is availability of a fluoridated public water supply. Approximately 60% of Americans live in communities that provide fluoridated drinking water, but over 100 million Americans live in communities that do not, including several large metropolitan areas with substantial Hispanic and African-American populations and many rural communities with low-income families that are underserved by dentists and physicians. The disease-prevention objectives of Healthy People 2010 include increasing the percentage of Americans with access to fluoridated public water supplies to 75% by the end of this decade.72
Oral Health: Summing Up
In summary, the oral health of Americans has improved dramatically in the past 50 years thanks to the impressive efforts of the dental profession and fluoridated water supplies. Yet, in 2001, substantial dental problems exist in a sizable group of children, living primarily but not exclusively in low-income communities. We say “not exclusively” because dental services still account for 25% of all health care expenditures for children aged 6–18.73 At the opposite end of the spectrum, a rapidly growing cohort of elderly patients is confronting dentists and physicians with intertwined dental and medical problems. Many of the elderly will have no dental insurance and will reside in extended care facilities that historically have not provided good oral health care services. For all age groups, child/adolescent, adult, and elderly, disparities in dental status and utilization of oral health care services are profound between the economic haves and havenots of our society.
Education Implications of Contemporary Oral Health
From our perspective as educators, contemporary oral health in America has four implications for the medical education and dental education communities:
- The most pressing oral health problems and issues in 2001 are no longer purely dental in nature; they fall into the overlapping educational and patient care environments of physicians, dentists, and other health care providers.
- In the 21st century, providing high-quality dental care and improving the oral health for all segments of society will be intertwined with public health policy, resource allocation, and care delivery/access issues. The dental profession will need to decide whether it wants to become a more integrated component of the overall health care system versus continuing the “splendid isolation” tradition of dental practitioners functioning in relative isolation from physicians and other health care providers. The dental profession will also need to decide whether a better foundation in public health policy will provide practitioners with a broader societal perspective on health care and more firmly establish prevention as a key role. In one of the very few office-based observational studies of activities and services in dental practices, only 2% of the dentists' time and 6% of the hygienists' time was devoted to prevention counseling.74
- Tobacco use plays a profound role in many oral health problems and is the primary contributor to other highmorbidity diseases. Dentists and dental hygienists are in an ideal position to play an important role in tobacco-use prevention and cessation, but have not done so aggressively, in part because of concerns about scope of practice, infringement on physicians' responsibilities, and lack of training.
- The evolving perception of oral health as an integrated component of overall wellness will exacerbate the dental profession's surreal-duality dilemma and fuel the current debate over curricular emphasis. Should the profession fully commit to an oral-physician concept or continue to promote the traditional tooth-doctor role? The bloated dental school curriculum indicates that both ends of the duality cannot be accommodated equally. The oral-physician concept implies an expanded scope of practice beyond tooth restoration and replacement that may test the boundaries of professional turf in the head and neck region with several medical specialties. Will medical professionals and educators view the oral-physician role as an infringement on practice or as a resource that can enhance patient care? On the dental education side of the fence, the technical and aesthetic traditions underlying restorative dentistry and prosthodontics are for many dentists the heart and soul of the profession and shape the culture of dentistry as a unique enterprise. Are dental educators ready to reconfigure aspects of the curriculum that are deeply intertwined with both the professional identity and the personal identities of hundreds of thousands of dentists trained in the United States since the 1950s?
II. DENTAL EDUCATION'S RESPONSE TO CHANGES IN ORAL HEALTH AND CURRICULAR-REFORM RECOMMENDATIONS
How has the dental education community responded to the evolution of oral health over the past 50 years? Tedesco75 documented dental education's response based on a chronologic review on numerous reports of curricular reforms, beginning with the pivotal 1926 Gies Report, which proposed recommendations similar to those of the Flexner Report. Tedesco's conclusion? The dental education community has responded to the winds of change with “some growth, and little change.” The typical dental school curriculum in 1997–98 primarily emphasized caries removal, restoration of excavated tooth structure, and creation of prosthetic devices to replace missing or defective teeth in adults, just as it did in 1950.76
But there is a well-developed agenda of reform. In addition to competency-based assessment, which is now mandated by the accreditation standards of the Commission on Dental Accreditation, the dental school reform agenda consists of ten recommendations similar to those advocated for medical schools:
- Decompress the curriculum by eliminating outdated and peripherally relevant material.
- Increase educational collaboration between dentistry and the other health professions, featuring more curricular emphasis on the interaction of dental and medical problems.
- Redirect basic science course work toward disease pathophysiology taught by problem-based techniques.
- Expose students to patients and their oral health and systemic medical problems from the first days of the curriculum to the last.
- Revitalize the science underlying clinical decision making via evidence-based approaches.
- Organize group-practice teams in the clinical years to promote more continuity in faculty—student relationships and expand peer teaching by students working together in clinical teams.
- Increase the use of community-based clinics as training sites for students.
- Include in the final year of the curriculum, or in a post-graduate internship year, a clinical experience that replicates the comprehensive care environment of the general dental practitioner.
- Utilize computer-based and Web-based information technology to enrich students' learning.
- Rededicate dental school clinics to serving the oral health needs of the public rather than primarily viewing patients as educational material for students.
For the most part, these reforms represent ideas advocated for many years but sporadically implemented. The IOM study of dental education concluded that
the problem in reforming dental education is not so much consensus on directions for change but difficulty in overcoming obstacles to change. Agreement on educational problems is widespread. The curriculum is crowded with redundant or marginally useful material and gives students too little time to consolidate concepts or develop critical thinking skills. Comprehensive care is more an ideal than a reality in clinical education, and instruction still focuses too heavily on procedures rather than on patient care.10
The dental education reform recommendations, taken collectively, argue for a learning environment that encourages students to learn collaboratively, provides students with opportunities early in the curriculum to practice application of newly acquired biomedical information by solving patient problems, fosters longitudinal contact between instructors and small groups of students, and provides learners with continuous contact with patients and their health problems throughout the educational program. These concepts are consistent with contemporary educational theory and are based on the inquiry-driven learning that students use to convert unorganized static information (i.e., data “sponged” from a text or a lecture) into the interlinked chains of networked knowledge (i.e., information that has meaning, utility, priority, and interconnections to other data) that experts access to solve problems (see Figure 1).77,78
Advances in PET (positron emission tomography) scan studies, fMRI (functional magnetic resonance imaging), and SQUID (superconducting quantum interference device) have provided neurophysiologists with technology capable of mapping how the brain functions during complex cognitive, perceptual, and psychomotor tasks.79 These studies indicate that expert practitioners (whose knowledge structure is represented in the bottom panel of Figure 1) have integrated neural networks that facilitate instantaneous retrieval of chains of knowledge relevant to task performance or problem assessment. The novice (whose knowledge structure is represented in the top panel of Figure 1), confronted with the same task or problem, struggles in a trial-and-error manner to assemble isolated bits of information (represented by the various symbols within the columns) because he or she lacks pre-existing knowledge chains. Problem-centered, collaborative learning is a strategy that helps novices develop the knowledge networks needed for expert function.80,81 There is also a growing belief among cognitive scientists that the structure and sequencing of information presented to students should parallel the way expert practitioners configure this information for on-the-job performance (e.g., experts access integrated webs of interrelated data).82
A substantial literature pertinent to the dental education reform agenda has emerged in the past ten years, including advocacy papers and implementation reports for competency-based assessment,83,84 reorganizing the basic science curriculum,85 evidence-based health care,86,87 problem-based learning,88,87 information technology,98–100 reforming clinical education,101–103 and the dentist's role in the overall health care system.104,105 The focal point for reform in both dental and medical education has been problem-based learning (PBL), particularly for reorganization of basic science content into multidisciplinary modules based on the organ systems, blending of clinical and basic science instruction to enhance relevance, and infusion of active learning into the curriculum. Assessment of dental education's response to PBL suggests why this strategy (which embodies several items on the reform agenda) and other educational initiatives have made only modest inroads.
The literature on PBL in the health professions is extensive, including comprehensive reviews of learning outcomes.106–110 PBL has a four-decade record of successful implementation, and the ability of students to learn effectively in well-orchestrated PBL programs is no longer debated by individuals familiar with the literature. Students in PBL programs cite the energy of intellectual exchange, sense of personal involvement, and stimulation of discovery as they collaborate to solve the health mysteries of the patient portrayed in the case. These are expressions of excitement about learning that stand in stark contrast to commentary about the tedious monotony of the lecture hall.111,112 Winston Churchill's commentary on his own education captures the positive attributes of PBL for many students: “I hate to be taught, but I love to learn.”6 Yet, PBL has not captured the imagination of dental educators to the extent it has been embraced by medical school faculty.
Four factors may contribute to PBL's failure to make significant inroads.
- First, PBL emphasizes the formulation of a broad-spectrum differential diagnosis, followed by data collection to rule out pathogenic options. At its heart, PBL is a detective game designed to help students identify problems, retrieve data, and ultimately solve the mystery. The purposes of PBL are to help students learn to play this diagnostic detective game, learn the normal structure and function of the human body, and learn the pathogenesis of abnormalities. The detective format of PBL, focusing on diagnosis, is not ideally suited to the traditional dental school curriculum, which emphasizes the other end of the spectrum—surgical and restorative treatment.
- The second factor relates to how PBL is used in the dental curriculum, which, from our perspective, is the most dense (i.e., numbers of courses and clock hours) and stressful (i.e., numbers of exams, deadlines and requirements) of all health professions curricula. Frequently, PBL is added to the curriculum as a correlation course to help students tie together basic science and clinical concepts. No free time is created for students to do research between tutorials; thus students perceive PBL to be an extra burden.
- Faculty concerns about effort-effectiveness constitute the third implementation barrier. To strengthen research programs and offset stagnation in state appropriations, dental schools are converting teaching positions into research-oriented positions that hopefully will generate state, federal, and private funding. The remaining teaching faculty are expected to devote more of their time to laboratory and clinical courses. Consequently, department chairs are hesitant to commit dwindling teaching resources to PBL, which is perceived to be faculty-intensive.
- The fourth factor relates to the nature of PBL itself. The back-and-forth, sometimes unfocused dialog that characterizes a dynamic PBL group can appear unproductive to faculty, who may prefer simply to tell students how to solve the problem rather than watch them flounder. Faculty discomfort with the facilitator role is evident in all health professions. But from our experience, it is more prevalent in dental education because few dental faculty have experienced PBL as students. The seemingly unstructured dynamics of PBL may not fall within the typical dental faculty member's concept of learning. In contrast, most medical school faculty educated in the past 25 years probably encountered PBL at some point in their training.
Summary of Implementation Barriers to Dental Education Reforms
The response to PBL mirrors factors contributing to “some growth, but little change” for other dental education reforms. These factors include hesitancy to deviate from the technical focus of dentistry's duality, narrow conceptualization among administrators and faculty as to what constitutes learning and teaching, lack of familiarity with alternatives to traditional lecture/lab instruction, unsuccessful efforts to add teaching and learning innovations as extra components to already jam-packed curricula, and perception among faculty with heavy teaching loads that these reforms represent extra work for the already overworked. In relation to work-load, concerns about faculty shortages have escalated to the point that school administrators are pondering whether they can continue doing business as usual. Fifty percent of dental school faculty are more than 50 years old and 40% of the 11,000 full- and part-time faculty will retire by 2010. The $60,000 income differential between private practice and academia has limited the number of new graduates who pursue university employment and has induced many young faculty to depart for economically greener pastures. It is estimated that academic dentistry needs to recruit 150–200 new faculty per year to maintain pace with current attrition, but in the past decade an average of only 80 of the 4,100 annual graduates (2%) have joined dental school faculties each year.113,114
If this trend continues, dental schools will need to develop more efficient ways to implement the curriculum, develop new models of education such as geographic approaches that pool school resources in a region, identify alternative sources of faculty such as community practitioners, or scale back the size of dental education nationally by reducing enrollment or closing schools.
III. FUTURE DIRECTIONS IN DENTAL EDUCATION
In this section, we review three directions for dental education that we predict can enhance the education of dental students: (1) developing a competency-based curriculum that may provide a more educationally sound learning environment and make more efficient use of faculty, (2) blending dental education into the mainstream of health professions education by increasing opportunities for clinical training in multidisciplinary environments, and (3) providing dental students with stronger training in public health.
Stimulated by the adoption of competency-based assessment as an accreditation standard in 1995, dental schools have done an admirable job of identifying competencies that students should acquire, and many schools are creating evaluation processes to measure these competencies.
However, few dental schools, if any, have attempted to restructure the curriculum and student learning methods around actual competency-based principles. From our perspective, developing a competency-based learning system is an important next step in the evolution of dental education. Hendricson and Smith described the three questions that faculty must answer to develop a competency-based health professions education curriculum:
- What knowledge, skills, and professional/personal values should the student possess at the time of graduation so he or she will be ready for the next level of training (e.g., a postgraduate year one) or be prepared to serve as an independently functioning entry-level general practitioner?
- What learning experiences will enable students to acquire these competencies?
- How do faculty know whether students have attained these competencies—what proof, or evidence, is needed to establish that a student has attained competency?115,116
A competency-based curriculum (CBC) has three features that are different from what most health professions educators have experienced: (1) top-down planning based on analysis of contemporary and predicted future health care needs of the public and the associated responsibilities of practitioners in the field, (2) a readiness-based model in which students advance through the curriculum at different rates from each other based on their individual capabilities, and (3) a horizontal curriculum structure in which students progress through competency modules hierarchically sequenced by difficulty level, and characterized by tight time proximity between laboratory learning and clinical experience. A number of developing nations employ the hierarchical structure of competency-based education to provide common pathways for training health care providers. For example, the modular curriculum of the School of Oral Health, Fiji School of Medicine, provides a competency-based ladder that prepares a student to function as a dental hygienist after two years, a dental laboratory technician after three years, a dental therapist capable of performing general dentistry services (e.g., tooth restoration, crowns, bridges) after four years, and a dental surgeon after five years.117
Grussing used the term “top-down planning” to convey the idea that competency-based curricula are derived from the roles, responsibilities, and frequently performed tasks carried out by practitioners to address the health care needs of the public.118 Grussing visualized the public's health problems and the associated roles and responsibilities of the care provider as the top, or pinnacle, of the educational mountain. Top-down planning leads to what is called a needs-based curriculum. For example, the Arizona School of Health Sciences, affiliated with the Kirksville College of Osteopathic Medicine, is planning to open a new needs-based dental school to address oral disease in Arizona, where 31% of children have never been to a dentist and 400,000 children have rampant tooth decay. As depicted in Figure 2, faculty develop the curriculum by working down from practitioner tasks and responsibilities to create an interlinked sequence of learning activities and assessments that prepare students for these responsibilities. The goal of top-down planning is to create an efficient pathway for the student that links competencies to subject matter and learning experiences, which, in turn, are linked to evaluations that measure performance of these competencies. The outcome is a series of hierarchically-arranged learning modules that start with universal foundation material (e.g., the building blocks for all subsequent learning) and progress sequentially through more sophisticated competencies.
In contrast, most faculty in health professions education are familiar with only bottom-up planning, which has been the standard operational model for 20th-century higher education. In bottom-up planning, certain pre-matriculation courses are accepted by tradition as being suitable prerequisites for entry into the professional program. Various courses are superimposed on top of these prerequisites, with each discipline building its own column of courses independent of other specialty areas, resulting in a silo curriculum that resembles the top panel of Figure 1. In the silo curriculum, basic science, behavioral science, and clinical disciplines train students independently (e.g., operate their own autonomous mini-curricula) with no planned cross-fertilization. When all courses in each of the discipline-based silos are passed, the student graduates. The assumption is that students, by their own devices, will assimilate, retain, and integrate the information from all these courses, and thus become competent, with minimal outside assistance.
Looking at health professions education overall, the silo approach is the prevailing model. At most academic health centers, each of the individual professions autonomously operate curricula with minimal planned interaction (although students from different programs may bump into each other by accident because they happen to be assigned to the same facility). The Institute of Medicine—National Academy of Science report, To Err is Human: Building a Safer Health Care System, examined the reasons for preventable patient-care errors and accidents that contribute to 50,000–100,000 deaths and several hundred thousand near-misses annually within health care facilities.119 Among many contributing factors, four educational conditions were identified: (1) the silo curriculum model does not provide multidisciplinary training that reflects workplace realities (IOM recommendation: “Train in teams those who will work in teams”); (2) because of reliance on memorization during training, health professions education produces entry-level practitioners with poor knowledge integration, poor vigilance for potential errors, and inadequate coping skills when problems occur; (3) entry-level practitioners lack training in information management systems and thus rely on memorization when on the job; and (4) there is a lack of opportunity to practice problem solving during training and on the job.
In summary, bottom-up planning, which typically produces a silo curriculum, helps faculty answer the question, What do we want to teach students about our respective areas of specialization? In contrast, top-down planning encourages faculty to answer these questions: What must our graduates be able to do so they can function as entry-level general practitioners without direct supervision and coaching? Or, what must our graduates be able to do so they can provide patient care at the next level of professional training, and benefit from educational experiences at the next level?
In a traditional time-based curriculum, it is assumed that spending a fixed number of years in training will ensure competency. In the readiness-based model of the CBC, students proceed through the educational program at different rates depending on individual capabilities. No arbitrary fixed time in training is set in the CBC. In other words, a student remains in training until he or she has successfully satisfied the requirements of competency assessments that document the ability to use designated skills in patient care without assistance. In the CBC, students and instructors jointly determine student readiness for competency assessments during which students perform without coaching and assistance by faculty. One student could be ready after two or three patient encounters, while another may require six or seven learning experiences to fine-tune the necessary patient care skills, assisted by the coaching, feedback, and modeling of faculty.
A CBC is also not repetition-based. In contrast to a readiness-based approach, in the traditional model of dental education, as evidence of clinical competence students are required to successfully complete within calendar deadlines required numbers of repetitions of a wide range of dental procedures, involving various types of amalgam, gold, and composite restorations, crowns, dentures, root canals, extractions, quadrants of periodontal scaling, etc. In this system, students' behaviors in the dental school clinic often revolve around finding patients who have oral health problems that allow them to perform required repetitions of the designated dental procedures. The requirement system has been criticized for creating an environment in which students are encouraged to place their own training needs ahead of patients' health care needs (e.g., talking a patient into undergoing a procedure the student needs to perform, but the patient may not need).120 However, several studies have demonstrated that dental students operating without requirements are just as productive as or more productive than peers in a requirement-driven system, receive an equally diverse clinical experience, perform as well or better on various indices of clinical performance, and report lower levels of stress.101,121–124 The use of absolute numbers of procedure repetitions as a marker of students' competence, and equating time in training with readiness to practice, are antithetical to competency-based assessment.
Horizontal Curriculum Structure
Competency-based curricula are structured differently from discipline-based curricula. A bird's-eye view of a traditional discipline-based dental or medical curriculum looks like the top panel of Figure 1, a series of silos representing the courses of autonomous disciplines. In contrast, Figure 3 depicts a bird's-eye view of a competency-based curriculum, derived from training models in the military and industry.125 In a CBC, students are evaluated before matriculation for their adaptability to the learning and assessment methods employed in a competency-based program. After matriculation, students participate in additional assessments to pinpoint the appropriate starting point for each student.
Most but not all students begin with a foundations phase where they learn patient care skills and biologic science concepts that serve as the universal underpinnings for all other areas of performance. Students have opportunities to apply these foundations by working with patients during the foundations phase.
The foundation biologic sciences courses for a competency-based health professions curriculum should be structured differently from traditional discipline-based basic science courses. In the process of consulting with dental and medical schools over the past ten years, the senior author (WDH) has interviewed more than 200 community practitioners and analyzed survey data from hundreds of residents who were requested to look back at their education. Practitioners and residents have a consistent vision of how they, from an educational consumers' perspective, would like to see the biomedical sciences structured. This vision is dramatically different from that reflected by the educations these individuals received. In the traditional silo curriculum, course directors organize their courses chronologically, topic by topic, from day one to the final examination (e.g., vertically) to introduce the subject matter to students in a logical progression for that particular topic. And indeed, most courses are well organized within the contexts of their particular silos in the overall curriculum. However, students experience the curriculum in a different manner as they try to make sense of information communicated in four to six concurrent courses taught back to back, hour by hour, in a single day (e.g., horizontally, across discipline silos). To illustrate this point, here is a list of the topics students encountered on a single day during the freshman year at a well-respected dental school with a discipline-based curriculum.
- From 8 to 9 AM: Pharmacology—diuretics
- From 9 to 12 AM: Gross anatomy—neuroanatomy of basal ganglia
- From 1 to 3 PM: Physiology—gastrointestinal motility
- From 3 to 4 PM: Microbiology—specific immunity
- From 4 to 5 PM: Biomaterials—metallurgy
Each course was well organized internally, but what is the impact on the learners as they attempt to make sense of fragmented and uncoordinated bits of information from five or more courses, each conducted independently? And this process occurs day after day throughout the curriculum.
In contrast to the approach depicted above, dental school graduates prefer what they frequently called a “lined-up” curriculum that coordinates morphology, anatomy, physiology, pathology, and treatment both for the head and neck region (craniofacial) and for the organ systems of the human body. Such a curriculum is arranged horizontally by broad related topics; for example, development (growth); structure (what is it? where is it?); function (how does it work?); pathology (what goes wrong?); and therapy (how to treat it?).126 This lined-up approach to curriculum organization is conceptually similar to the knowledge networking (often described as horizontal linkage) that apparently serves as the underpinning for the development of expertise.
The 1999–2000 AAMC Curriculum Directory indicates that more than 100 U.S. medical schools (roughly 70%) have implemented an approximation of the horizontally lined-up model (e.g., thematically integrated versus purely discipline-based courses) for either the first year or the second year, or the bulk of both years. In contrast, integrated basic science curricula in North American dental schools are rare. Forbes found that 90% of the associate deans for academic affairs endorsed the concept, but only ten schools operated curricula that blended basic science courses together.127
After completion of competency tests to certify acquisition of the biological and clinical foundations, CBC students move through a hierarchy of learning modules that provide learning experiences and assessment for increasingly complex competencies, in a building-block approach. An important feature of the hierarchical CBC model is that interrelated preclinical experiences (e.g., developing basic technical skills in a laboratory) and clinical experiences with patients both occur within learning modules throughout the curriculum rather than via the traditional system of limiting laboratory work to the first half of the educational program and clinical work to the third and fourth years.
Thus, it is possible that even students in the final phase of the curriculum may spend time learning new skills in a laboratory. On the first day of the laboratory, students are assembled into learning teams (often called learning “squads” per the squad concept in military applications of CBC) of six to eight students led by an instructor (team leader) who is assisted by one or more senior students who serve as teaching assistants (TAs). The squad of students, instructor, and TAs work together every day in the lab and also move together from the laboratory into the clinic to ensure continuity of learning between laboratory and clinic. The key to the horizontal CBC format is the continuous relationship of an expert practitioner with a small group of novice learners in the tradition of the artisan—apprentice training model perfected during the 15th- and 16th-century Renaissance by the masters of various craft guilds. When students test out of the laboratory phase of the module, they move into the clinic and perform the procedure on patients, with coaching and feedback from the team leader and TAs, within days of passing the laboratory competency examination. Competency assessment in the clinical phase of the module is accomplished by the triangulation method, which consists of three measurements of different aspects of competence: assessment of the student's ability to perform procedural skills, a case-based written assessment of the student's ability to use knowledge to make patient care decisions, and the team leader's overall assessment of the student's performance, including patient management, ability to communicate biomedical knowledge, technical skills, and professional demeanor.
Upon successful demonstration of competency, students enter a new module where they are reorganized into new learning squads, meet new instructors and TAs, and repeat the process. However, in some CBC formats, the learning squad remains intact for several competency modules, depending on the expertise of the team leader. Students who do not demonstrate competency repeat the module. The ultimate layer of the curriculum is an extended period of comprehensive practice, involving all competencies. To graduate, during the final curriculum layer students must successfully complete competency examinations that measure key skills and the ability to demonstrate professional values when interacting with patients.
An educational advantage of the CBC is the tight time relationship between laboratory simulation and use of these skills during patient care. In the traditional dental curriculum, six to 12 months may elapse between a student's laboratory experience and performance of the learned procedures in the clinic. The literature on acquisition and maintenance of complex procedural skills indicates that performance erodes within several weeks if the skill is not continuously practiced and fine-tuned by self-assessment and instructor coaching.128 The CBC learning squad structure would also alter the management of patients within the clinic. In most dental school clinics, patients are assigned directly to students, not to clinicians serving as faculty. Faculty basically serve as evaluators who inspect the students' work at various points in the treatment process and assign grades. Thus, dental students primarily encounter clinicians as checkers rather than as mentors and rarely observe faculty in a care-provider role. Instead of seeing faculty as role models and teachers, dental students have historically focused on the gatekeeper (grader) role of clinician faculty. This produces a higher level of guarded, hunkered-down behavior among dental students than we have observed among students in other health professions education programs. In contrast, the faculty leader of each CBC learning squad would assume responsibility for patient management and would coordinate the diagnostic and therapeutic activities of the squad, providing some care also, especially early in the module, and assigning other tasks to students and/or the senior TAs working with the squad.
Competency-based Curriculum: Time and Resource Efficiencies
A competency-based format may alleviate two other problems in dental education: escalating student indebtedness and faculty shortages. Research on the CBC indicates that the readiness-based model allows learners to proceed through training faster than does the traditional time-based approach.80,129 Some medical residency programs have adopted the readiness-based CBC and report faster learner progression toward competence. For example, neurosurgery residents at Johns Hopkins mastered a variety of complex competencies from three to 18 months faster after implementation of a CBC format.130 Implementing a training system in which students can graduate in a shorter time frame will obviously ease the students' financial burden and provide resource economies for the institution.
Because of the squad-continuity concept, competency-based programs typically do not use the FTE (full-time equivalent) coverage approach in which several instructors fill one faculty slot in the clinic during the week. In the CBC, one faculty member is assigned full-time to each learning squad that moves as a unit through the clinical modules. Senior students provide the primary instructional support for the team leaders rather than faculty. For example, a CBC class of 100 would consist of approximately 14 teams and require full-time teaching commitment from 14 instructors plus a couple of rovers. In our experience, a typical clinic week for 100 students in a traditional curriculum might be staffed by up to 25 different faculty from the various departments. Because of the full-time dedication of one instructor to a squad of students, CBC staffing is lean and mean in comparison with conventional approaches. Of course, the down side is that certain faculty are designated as full-time teachers and have no time for other academic activities. Therefore, the CBC requires modification to the triple-threat approach to promotion and tenure to avoid placing competency team leaders in jeopardy.
A 21st-century Curriculum Model for Dental Education
A number of medical schools structure their curricula in the AM—PM format (i.e., morning and afternoon), which is a viable format for the foundations phase of a competency-based dental school curriculum.131 In the AM—PM model, eight of the ten half-day blocks during the week are scheduled for learning experiences and two half days are unscheduled. In the morning, thematically integrated basic science courses are conducted four days a week (blocks 1–4). During two afternoons, students meet in PBL groups from 1 to 3 PM to analyze cases that require application of concepts derived from the biologic science instruction (blocks 5–6). The remainders of these afternoons are unscheduled so students can research questions arising during the PBL sessions. On a third afternoon, students participate in a physical assessment lab to learn patient examination pertinent to an anatomic area or pathologic mechanism addressed at that point in the curriculum (block 7). Students spend a half day per week at a clinical site assisting third- or fourth-year students with patient examinations (block 8).
In our vision of the 21st century dental school curriculum, four half-day blocks in the morning will be devoted to the biologic science units depicted on the left side of Table 2. The titles of the numerous courses that traditionally comprise these thematic units are indicated on the right side of the table. Each thematic unit will employ an integrated cross-disciplinary approach based on the lined-up horizontal structure. The four half-day PM blocks will be devoted to a PBL integration session (block 5) to help students pull together biologic principles and three blocks devoted to foundation patient care skills (blocks 6–8; 12 hours per week). In addition to learning foundation dental skills, we recommend that dental students also learn how to take a full medical history and conduct a comprehensive head-to-toe physical examination. Patients with oral disease and common medical comorbidities such as arthritis, cancer, cardiovascular disease, and diabetes should serve as physical assessment subjects. Interviewing and examining individuals who have active disease, at the same time as taking pathophysiology course work, will allow dental students to see the clinical presentations of medial conditions and demonstrate the intermingling of dental and medical problems. By the middle of the spring semester, first-year students should assist upperclassmen two half days a week and have a weekly halfday preceptorship in a hospital-based dental clinic where the interplay of patients' medical and dental problems is evident and students can encounter a primarily geriatric patient population.
As depicted in Appendix A, we recommend dividing each clinical year into four ten-week competency modules, with two-week mini-modules scheduled after modules one and three for focused pursuit of elective topics. Two of the six mini-modules in the second, third, and fourth years should address health services research and require the student to conduct an evidence-based investigation of an oral health topic. For the remaining four mini-modules, the student can choose from an additional research topic, clinical experiences in dental or medical subspecialties, comprehensive dentistry in a community setting, or a rotation in the school's walk-in emergency clinic. One of the ten-week competency modules should be devoted to pubic health, with a community service component and completion of an evidence-based research project. Fourth-year students will also serve one day per week as TAs in the foundation skill labs for first-year students or as TAs in lower-level competency modules. The competency modules in the second, third, and fourth years should be arranged in a stairstep continuum that allows the student to progress through basic skills underlying many areas of clinical care before progressing to more complex competencies. To stimulate thought, particularly among dental educators, a hypothetical clinical module sequence is proposed in Appendix B.
Blending Dental Education into the Mainstream of Health Professions Education
The IOM Report on Dental Education recommended that “dental educators should work with their colleagues in medical schools and academic health centers to require and provide for dental students at least one rotation, or clerkship, or equivalent experience in relevant areas of medicine, and offer opportunities for additional elective experience in hospitals, nursing homes, ambulatory care clinics, and other settings.”10 The IOM report also recommended that dental school faculty should have sufficient experience in clinical medicine that they—and not just physicians—could impart core medical knowledge to dental students and be clinical role models to students in regard to recognition and appropriate responses to medical disorders in patients.
Our view is that the dentist is a health care provider who has received specialized training in assessment and treatment of diseases and abnormalities of the orofacial complex, an anatomically and functionally-defined region similar to the anatomic or functional parameters that establish practice domains for other medical specialties and subspecialties. The key question is: Should the education of the orofacial specialist be better assimilated with the training for students preparing for careers in other areas of medical specialization? A number of factors indicate to us that the answer is “yes.” As we have seen, numerous high-morbidity diseases and abnormalities of the orofacial complex can benefit from multidisciplinary prevention and treatment. For example, advances in microbiology suggest that reducing maternal reservoirs of mutant streptococci, preventing transmission of bacteria from mothers to infants, and enhancing the child's resistance to bacterial implantation are viable approaches to primary caries prevention.29 Implementing those preventive measures and educating the public about the infectious transmission of caries requires teamwork between pediatricians, dentists, and public health workers.
In addition, the growth in the number of elderly patients, with medical and dental comorbidity, will place dentists and physicians in more frequent collaboration to coordinate treatment for this population. Research in molecular biology and investigation of the genetic basis of disease have transcended traditional disciplinary boundaries, blending the efforts of dental and medical investigators with the expertise of basic scientists. Access to the Internet and other sources of health information has enhanced public awareness of disease processes, medications, non-pharmacologic therapies, diet and fitness, and alternative medicine, which places pressure on all health care providers to stay abreast of developments across a broad spectrum of biomedical knowledge.
And finally, academic health centers (AHCs) are struggling to determine the winning combination that will enable them to compete in the marketplace. Many AHCs hope to entice patient enrollment by assembling attractive packages of multidisciplinary service teams. Given the uncertainties of core financing for university-operated clinics, dental school administrators now understand the need to demonstrate the value-added potential of the dental school clinic, within an overall spectrum of health care services.132 The Blue Ridge Academic Health Group, a component of the University of Virginia Health Policy Center, which consists of academic health professionals, sociologists, economists, and businessmen, advises AHC administrators who are reconfiguring organizational structures to enhance economic viability. The Blue Ridge Group recommends that “AHCs must base their management structures and programs on the collective enterprise. Individual components of AHCs that perceive themselves as independent and isolated must come to view themselves as an integral part of a common enterprise, and must commit to collaborative accomplishment of common goals and objectives.”133
If there are substantial reasons for blending the education of dentists with that of physicians-in-training, how can this be accomplished? The IOM recommendation to add a medical clerkship to the dental curriculum is problematic. Clerkship directors are hard pressed to locate training sites and adequate numbers of university-based or community physicians for their own students, so adding dental students to the clerkship mix is doubtful. However, there are other ways to diversify the dental students' clinical experience and increase interaction with other health professionals. The 21stcentury curriculum proposed in this article has three mechanisms to accomplish these goals.
- First, the whole-body physical assessment in the foundations phase will alert students to the interplay of oral and systemic diseases while they are learning about pathophysiologic mechanisms and will encourage students to view patient health holistically, not just from the perspective of the oral cavity.
- Second, the 21st-century curriculum should include a tenweek multidisciplinary health care module in the second year that focuses on five areas where dentists and other health care professionals will increasingly interact in the future: ear, nose, and throat; oncology; hospital-based dentistry; pediatrics; and geriatrics (two-week rotations in each area). It is particularly important to provide dental students with experiences in the hospital environment and with elderly patients early in the curriculum. Many dental schools already have rotations in hospital dental clinics, but usually at the end of the curriculum. An early hospital rotation will provide students with patient care experiences that blend oral health and internal medicine. The hospital dental service is also the environment in which students are most likely to observe dentists functioning in an oral-physician role. The geriatrics rotation should include home visits with the elderly. For example, first-year medical students at the University of Texas Health Science Center at San Antonio meet “senior professors” who are geriatric volunteers willing to share their life experiences and medical histories with students.134 During years three and four of clinical training, dental students should also provide care to elderly patients at long-term care facilities.
- The third mechanism for diversifying the dental students' education comprises the mini-modules, which can provide cross-disciplinary experiences in many areas: genetically-based craniofacial anomalies, maxillofacial prosthetics, disorders of the temporomandibular joint, reconstructive surgery for facial trauma, HIV infection, substance abuse, psychosocial—behavioral issues, and community-based prevention services.
Although it is not the focus of this article, we believe that residents in the medical primary care disciplines, particularly pediatrics and family medicine, should receive expanded training in oral health assessment and prevention. Pediatricians and family physicians see children regularly, but they typically receive rudimentary training in oral health issues in their residency programs.135 The situation is complicated by the fact that there are only 3,500 pediatric dentists in the United States, and most general dentists practicing today received very limited training in providing dental care for infants and young children.15 To address this gap in oral health care for children, Mouradian recommends that physicians training to be primary care providers should learn oral health assessment techniques, learn how to provide caries prevention counseling to children and parents, and learn basic techniques for caries control such as applying fluoride varnishes.15 We recommend that the third-year family medicine clerkship include a rotation in an oral diagnosis screening clinic where medical students can work up patients (who typically have plenty of systemic disease) in conjunction with dental school peers. The third-year pediatrics clerkship should include a module on oral health, and medical students should learn how to assess a child's oral health status as part of the routine physical assessment protocol.
Building Alliances for Multidisciplinary Education
Medical—dental school alliances exist now, which suggests that the obstacles are not insurmountable. Medical school anesthesia and surgery departments cooperate with oral surgery in support of predoctoral and graduate training, including DDS—MD dual-degree programs. Dental and medical faculty collaborate in the research and teaching activities of federally-funded geriatrics education centers and provide joint staffing for university-operated extended-care centers. Clinical research centers for craniofacial disorders and maxillofacial prosthetics include dentists and physicians. Several dental schools provide four- to six-week hospital externships for their students.
From our perspective, four strategies for cross-disciplinary alliance building are available: (1) cross-appointment of dental and medical school faculty in areas with overlapping interests such as pediatric dentistry with medical pediatrics, general dentistry—community dentistry with family and community medicine, and periodontics with internal medicine; (2) budget re-direction in which schools purchase the services of other AHC components, a model already used by dental and medical schools to implement the basic science curriculum; (3) collaboration of medical and dental schools in recruitment of dual-degree faculty who have the breadth of training and experience to teach in both schools; and (4) service exchanges in which departments support each other's educational program in repayment for clinical services. For example, the dental school provides staffing and equipment for the medical school's mobile health vans in exchange for the medical school's providing slots for dental students in clinical electives, or vice versa.
Expanded Focus on Public Health and Tobacco-use Prevention—Cessation
During the third year of the 21st-century curriculum, students should complete a public health competency module that features field investigation of community health problems, training in evidence-based literature review, and presentation of an evidence-based research report. The nature of oral disease in the 21st century and the demographics of populations in greatest need of dental services suggest to us that the dental education community should carefully consider the long-term value-added potential for the profession and for the public of providing more joint DDS—MPH degree tracks at dental schools, and also perhaps establishing a national goal to graduate a certain percentage of students with the DDS—MPH package (for example, 25% of graduates by 2025). With proper scheduling, a student should be able to complete a dual degree in five years with summer work, especially if a readiness-based CBC is implemented.
Dental students should receive enhanced education about tobacco use and its associated health problems and receive training in tobacco prevention and cessation techniques. The American Dental Association has advocated a more proactive role in tobacco prevention and cessation for its members, and models have been developed for education of dentists-in-training and community practitioners.136–138 Because of the dentist's focus on the oral cavity, where signs of smoking are obvious and effects are profound, it seems to us that the dental profession can be a first line of defense against this insidious practice, a new and critically important disease prevention role for the profession.
IV. SOCIOLOGY OF CHANGE IN HEALTH PROFESSIONS EDUCATION
After assessing the wreckage of a failed attempt to revise the curriculum, a medical school dean captured the challenge of reform, “It is not enough to have good ideas. Other factors are much more powerful.”139 Goffee, Berquist, and Schein studied university culture and faculty values as the basis for analyzing adaptability to change.140–142 They observe that university faculty value independence and autonomy, do not value collaboration, but have a strong need for job security and insulation from risk. Goffee envisions the organizational culture of an institution as a matrix with two axes, a vertical one representing solidarity (cohesiveness of purpose among organization components), and a horizontal one representing sociability (interpersonal relationships among persons in the organization). The levels of solidarity and sociability can be high (strong solidarity and much sociability) or low (weak solidarity and minimal effort at sociability). Goffee concludes that “university faculty, identifying more strongly with their disciplines than with the university itself, typically lack solidarity. Their interpersonal relationships (sociability) may be distant as well, placing the university low on both solidarity and sociability,” thus making the university culture particularly resistant to change.140
Dentists have been described as cautious, conservative, valuing order and conformity, with a desire to control events.143 Not surprisingly, the independent yet cautious nature of the faculty is reflected in the organizational structure of dental schools, most of which operate under a decentralized states'-rights philosophy that encourages autonomous action by departments, an organizational structure similar to that of most medical schools. Ebert and Ginzberg describe medical schools as a confederation of semi-autonomous fiefdoms that seemingly exist to compete with each other for treasure (institutional resources), territory (office, laboratory, and clinic space), and political influence (curriculum time).144 Just as when Julius Caesar observed, as he stood on the banks of the Rhine gazing at the first bridge to span the river from Germania into Gaul (France), that “most certainly, commerce will follow this means of transportation,” so also curriculum most certainly follows the school's organizational chart.145
Given these factors, resistance to change in the university environment is the norm rather than the exception. Dental education is not alone in its inability to institute meaningful reforms. Samuel Bloom's classic discussion of resistance to change in medical schools reviewed the myriad efforts since 1920 to improve medical education and observed that the process was characterized by “reform without change.”146 This conclusion was echoed by Christakis, who assessed the marginal impact of 19 national-level efforts to reform medical education.147 Bloom and Christakis both identified organizational structure and the cultural environment of the institution as the major barriers to educational revitalization.
The process by which educational institutions respond to changes in policy, resource allocation, or structure is predictable. Reform efforts in institutions with complex infrastructures proceed through the following phases:
- Denial: A self-protective state to avoid being overwhelmed
- Resistance: Mourning and distress; passive-aggressive resistance
- Acceptance: Inevitability of impending change is recognized
- Bargaining: Attempts to piecemeal or sequester the new plan
- Exploration: Future-focused thinking about how to integrate the new plan into the mainstream of the institution
- Commitment: Proactive efforts to make the new plan work effectively
- Comfort: The plan is no longer “new” but is perceived as routine and “our way”148,149
Most reforms fail to move beyond the denial or resistance stages, particularly when they are not provoked by a galvanizing event that reflects poorly and publicly on the institution (for example, poor board scores, a high student attrition rate, or media reports of faculty unhappiness). Reforms may reach the bargaining stage if leadership persistently focuses attention on the problem and articulates a viable solution (e.g., a new organizational reality), a process known as reality framing.150 Levine identified enclaving and piecemealing as particularly effective and frequently-used bargaining strategies that block educational innovations.149 Reforms often are enclaved, or quarantined, as detached programs that sequester reformers away from conventionally-minded faculty, and limit disruption of standard operations. Quarantined programs typically wither when reformers depart or assume new responsibilities. In piecemealing, departments adopt only the components of reform packages they can live with and ignore less agreeable aspects. Departments will enclave and piecemeal until they reduce reforms to small components that have negligible impact on departmental structure and operations, a minimalization process leading to reform without change.
Noer developed a model to assess the likely response of an organization to a reform initiative.151 Noer's response-factor model categorizes organizations along two dimensions—capacity for change and comfort with change. Dental schools can best be described as “entrenched” organizations, with high capacity for change, but low comfort with change. Entrenched organizations respond to change by blaming and complaining, acknowledging the need to change but resisting efforts to modify philosophy, structure, and operations, working harder at previously successful behavior patterns, and riding it out until things return to normal. We believe dental schools must aspire to become what Noer categorizes as “learning” organizations, which have high capacity for implementing change and high comfort with the processes necessary to support and maintain innovation. Learning organizations respond quickly to challenges and deficiencies by developing new strategic directions, focusing on solving problems rather than casting personal blame, and accepting short-term setbacks in exchange for long-term enhancement of operations. As Peter Drucker states, “One cannot manage change. One can only be ahead of it.”152
The literature on organizational change in health professions education indicates that the chief executive officer (CEO) is “the straw that stirs the drink.” Bland and colleagues reviewed the literature reporting curricular change strategies and outcomes in higher education and identified 35 factors that contribute to successful reform.153 Bland grouped these success factors into 13 categories such as organizational structure, scope of the innovation, and leadership. Of these factors, leadership stood out. “Leadership comes up again and again as critical to the success of curricular change because the leaders control or substantially influence nearly all the features essential for success.” Without strong CEO leadership, clear vision of a different but desirable future, persistent promotion of the vision, excellent behind-the-scenes organization, and willingness to face down obstructionists, true reform is not likely to occur. Deans must resist what Lencioni refers to as leadership temptations, with the foremost temptations being (1) the equation of personal popularity with successful management and (2) focusing on personal achievements rather than organizational results as indicators of performance.154 Instead, Lencioni contends that CEOs should make institutional outcomes the most important measure of their own personal success, organize and manage faculty in ways needed to achieve desired results, work for the long-term respect of faculty as opposed to their affection, and take decisive action. The associate deans who work with the dean must share these leadership abilities and wholeheartedly support the vision. Several universally respected faculty leaders must also share the vision, have the same passion for making improvements, and be willing to stick their necks out among peers to endorse what may be unpopular recommendations. Evaluation of curricular innovation projects at eight medical schools funded by The Robert Wood Johnson Foundation indicates that a bookends approach to leadership (dean and associate deans on one side; respected faculty leaders on the other) is vital to success.155,156
Faculty development and reconsideration of organizational structure will be key ingredients in whatever direction dental and medical education take in the next 20 years, independently or jointly.
Most dental schools have operated discipline-based curricula for decades (year 1 = basic science lectures with a few preclinical labs; year 2 = preclinical labs, a few basic science courses, and a get-ready-for-clinic experience; years 3 and 4 = primarily clinical, divided into specialty and generalist-focused components). Few dental school faculty have experienced educational programs that are not close approximations of this model. This is a limiting factor when seeking new approaches because teachers “like what they know best” and “teach the way they were taught.” Consequently, resources must be devoted to professional development programs that prepare faculty for different roles in new curriculum formats. The outcomes of the Robert Wood Johnson curriculum-innovation projects and evaluations of other reform efforts in medical education demonstrate that preparing faculty to assume new academic responsibilities is vital to successful conceptualization, implementation, and maintenance of the reform.153,157–159
Bloom and Magill observed that the discipline-based structure of health professions education institutions is a direct descendent of the organizational structure of the German research university in the mid-19th century.146,160 In 1850, subdividing university resources along purely disciplinary lines made sense because cross-disciplinary research was not even a consideration, given the dim awareness of biologic mechanisms underlying disease and the unsophisticated technology available to investigate biologic questions. Now that we are in the 21st century, does the organizational structure of the 19th-century German research university still provide the most appropriate environment for educating health care professionals? Academic administrators in both dentistry and medicine will need to address this question.
We conclude with a reminder from the 16th century:
There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things—because the innovator has for enemies all those who have done well under the old conditions … but only lukewarm defenders in those who may do well under the new.
NICCOLO MACHIAVELLI, The Prince 161
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Proposed Sequence of Clinical Competency Modules
- Diagnosis, prevention, and treatment of periodontal disease, including an interdisciplinary rotation on surgical skills
- Restoration of dentition
- Management of dysfunction/abnormalities of the craniofacial complex (a multidisciplinary module addressing growth and development abnormalities from childhood to adulthood)
- Multidisciplinary health care—ENT (ear, nose and throat), oncology, pediatrics, hospital dentistry, geriatrics (two weeks each; total of ten weeks)
- Two mini-modules for clinical or research electives (two weeks each)
- Clinical Practice of Dentistry (CPD) = two-three hours per week devoted to: (1) Pain Management and Clinical Pharmacology and (2) Economic Basis of Health Care Systems
- Endodontics and inter-arch restorations
- Removable restorations (partial and complete dentures)
- Public health including a community field-work project and an evidence-based project
- Primary dental care (comprehensive care)
- Two mini-modules for clinical or research electives (two weeks each)
- Clinical Practice of Dentistry (CPD) = two-three hours per week devoted to (1) Clinical Pathology Conferences, (2) Clinical Pharmacology, and (3) Dental Informatics
- Oral surgery, management of trauma and emergencies, and dental walk-in clinic
- Implant dentistry and esthetic dentistry (five weeks each)
- Primary care (including a two-week hospital dentistry rotation)
- Primary care (including a two-week practice management preceptorship/project)
- Two mini-modules for clinical or research electives (two weeks each)
- Clinical Practice of Dentistry (CPD) = two-three hours per week devoted to: (1) Dentist in Society, (2) Professional Ethics and Jurisprudence, and (3) Dental Practice Management
A hypothetical class of 80 is divided into four groups of 20 students who rotate among the modules. Patient treatment in junior year competency modules that may extend beyond the confines of a ten-week rotation (for example, multi-unit fixed bridges or partial dentures) can be completed during the weekly comprehensive care days scheduled throughout the year and/or during the Primary Care Module, depending on the student's rotation schedule.