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Critical Issues in Dental Education |
Dr. Kassebaum is Executive Associate Dean, University of Colorado School of Dentistry; Prof. Hendricson is Director, Division of Educational Research and Development, Department of Academic Informatics Services, University of Texas Health Science Center at San Antonio; Dr. Taft is Director, Educational Development, Marquette University School of Dentistry; and Dr. Haden is Associate Executive Director, American Dental Education Association. Direct correspondence and requests for reprints to Dr. Denise K. Kassebaum, University of Colorado School of Dentistry, 4100 E. Ninth Ave., Box C-284, Denver, CO 80262; 303-315-8891 phone; 303-315-0472 fax; denise.kassebaum{at}uchsc.edu.
Key words: dental curriculum, problem-based learning, community-based experiences
Submitted for publication 06/08/04; accepted 07/09/04
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Abstract |
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Have North American dental schools responded to these calls for reform by making significant changes to the dental curriculum? Tedesco5 reviewed the numerous dental curriculum reform reports over the past seventy-five years since the pivotal 1926 Gies Report and reached the conclusion that the dental education community had responded with "some growth and little change." The most common criticism of today’s dental curriculum is that it is excessively dense, in terms of the number of courses and clock hours. This curricular density is perhaps a byproduct of the tension between faculty who favor expanding the biomedical emphasis of the curriculum to allow dental practitioners to assume an even greater role in managing a patient’s health and those who want to maintain a traditional technical focus.6 Writing in 1995, Tedesco observed that "attempts to make the basic sciences relevant to clinical practice, to protect the curriculum from overcrowding by maintaining time for reading and independent study, and to produce lifelong learners with a spirit of inquiry and highly professional, ethical standards are 60 years old."5 Hendricson and Cohen reported that there is "a well-developed agenda of reform. For the most part, these reforms represent ideas advocated for many years but only sporadically implemented."6 The 1995 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.1
Hendricson and Cohen identified eleven dental education reform recommendations that have been consistently advocated over the years.6 These recommendations appear in Table 1
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Will these factors catalyze change in the dental curriculum? For example, the 2003 report of the ADEA President’s Commission, "Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions,"10 makes several recommendations that could have a profound effect on dental education, including:
The purpose of this article is to report the results of a survey completed by the academic deans of fifty-six North American dental schools to determine the format of their respective curricula and to identify innovations recently implemented or planned for the near future. Respondents also identified issues that influenced curricular change at their schools. Survey responses are analyzed in light of the dental education reform agenda in Table 1
. We hope that the presentation of the results of these data will stimulate dialogue about strategies for strengthening the future dental curriculum and dental education programs.
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Methods |
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The academic deans who received the survey were asked to indicate the name of their school and respond to questions in ten areas: 1) organizational structure of their curricula, 2) extent of integration around themes or threads of interrelated topics, and 3) the degree to which problem-based learning (PBL), case-reinforced learning (CRL), and community-based patient treatment experiences were incorporated. Respondents were also asked to identify: 4) methods employed to assess curriculum effectiveness, 5) innovations implemented in their curriculum during the past three years, 6) projected curriculum changes over the next three years, 7) reasons for considering curriculum changes, 8) the number of current faculty vacancies and the impact of these vacancies on curriculum implementation, 9) resources needed to make future curriculum changes, and 10) roles that ADEA should play in regard to dental school curriculum.
To increase the consistency of responses for questions about PBL, CRL, and community-based patient treatment, the following definitions were provided on the survey:
PBL = No lectures; students learn by a discovery method through exploration of patient problems in small groups guided by faculty facilitators; students take responsibility for guiding their own learning and from peer teaching.CRL = Students participate in small-group, case-based conferences to reinforce lecture-based instruction. In CRL, cases allow students to discuss application of lecture information and to use this information to analyze problems.
Community-based clinical treatment experiences = opportunities for dental students to provide care in community-based clinics or private practices (emergency services, periodontal, restorative, endodontic, pediatric, or other dental specialty care). The term "community-based clinical treatment experiences" is not intended to be synonymous with community service activities where dental students might go to schools to teach preventive techniques or where dental students help build homes for needy families.
Some questions required the selection of one best answer while others asked respondents to check all items that applied from a menu of responses. Statistical analysis consisted of producing descriptive statistics (frequency distributions) for each survey item. Respondents were also able to write in responses to augment their answers for most of the questions on the survey.
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Results |
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Respondents indicated the name of their school and answered survey questions divided into ten sections previously described. In response to the question about curriculum structure, 66 percent defined their curriculum organization as largely discipline-based with a few interdisciplinary courses (Table 2). Fifty-nine percent of schools reported that they used problem-based learning in either individual courses or in specific components of some courses, but only 5 percent of the respondents (n=3 schools) indicated that all of their courses used the PBL format (Table 3). Thirty-eight percent of schools (n=21) reported that they used case-related learning in all or some components of courses (Table 4). Regarding the integration of major sections of the curriculum (Table 5), only 7 percent (n=4 schools) reported that their entire curriculum was organized around themes of interrelated topics, and 16 percent reported that at least one major section of their curriculum was organized around themes. A high percentage of schools (64 percent) reported that their students were required to complete community-based clinical treatment experiences (Table 6); however, there was considerable variation in the amount of community-based experiences from school to school. Of note, only one school indicated that the dental curriculum did not contain either required or elective community-based clinical treatment experiences.
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). Student evaluation of courses and instructors, comparison to accreditation guidelines, National Dental Boards examination results, faculty opinions about the curriculum, and results of course evaluations by internal curriculum committees were each selected by at least 95 percent of the respondents.
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). Increased use of computer-based technology (86 percent) was the most frequent innovation, followed closely by creating more opportunities for freshmen and sophomores to interact with patients (84 percent) and creating better methods to evaluate student competence (84 percent). Other curriculum innovations during the past three years that were reported by more than 70 percent of respondents were decompressing the curriculum, creating more opportunities for students to learn evidenced-based dentistry, and creating more opportunities for students to learn and conduct research.
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). The response selected most often was "increase the use of computer-based technology" (82 percent). The next most frequently selected responses were "create better methods to evaluate student competence" by 57 percent, decompress the curriculum (55 percent), and increase community-based patient care (54 percent).
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), the response selected most frequently was "recognition that we need to make better use of resources" (59 percent), followed by the need to incorporate new scientific findings (54 percent) and alumni feedback and recommendations (48 percent).
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displays the resources that schools identified as essential for implementing planned curricular changes. Eighty-eight percent of respondents identified "faculty development related to curriculum, evaluation, and assessment" as an essential resource needed for future change. Other frequently identified resources included improving information technology capabilities (59 percent), providing faculty with protected time for curriculum work (59 percent), and increasing the budget for curriculum development (54 percent).
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). Forty-two schools answered yes to this question (75 percent). However, 90 percent of respondents reported that they did not see a need to restructure the curriculum in the short term because of faculty shortages.
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). Table 14 indicates curriculum-related initiatives by ADEA or other organizations that were perceived to be helpful by a majority of respondents including: distributing curriculum models from schools with innovative approaches (84 percent), conducting national or regional conferences to stimulate curriculum innovation (78 percent), distributing curriculum best practices (71 percent), provide funding to promote research on the effectiveness of curriculum strategies (63 percent), and publish manuscripts on curriculum change (63 percent).
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Virtually all respondents provided write-in comments to amplify their responses. These write-ins were transcribed verbatim and analyzed for key themes. Three key themes emerged from this analysis. First, nearly half of the respondents described efforts to move toward more interdisciplinary curricula but observed that the process is "slow and difficult," "departments remain territorial," and "change is a slow and humbling process." Second, some respondents said that their schools had implemented many of the innovations years ago and thus these changes were "not new anymore" for them, a factor that should be considered in analyzing the survey results. For example, several respondents commented that PBL hardly qualifies as a "new" innovation because it has been around since the 1960s. Third, nearly one-third of the respondents reported that their schools had just started a significant restructuring or were already in transition to a modified curriculum that will take several years to fully implement.
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summarizes our interpretation of the degree of implementation of these reforms based on the findings of this survey. The first item on the reform agenda, competency-based education, cannot be addressed because there were no questions on the survey related to this reform.
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During the annual Curriculum Forum at the 2004 ADEA Annual Session, more than 100 dental educators, including many deans and associate deans for academic affairs, were asked this question: what is your top priority for curriculum innovation? The overwhelming answer: decompress the curriculum. Thus, it appears that the decades-long drumbeat of criticism about the overly dense dental school curriculum has captured the attention of educational leaders in dental schools. However, in our experience, the essential first step in curriculum decompression is to forget about the word "decompression" and instead focus on the task of making thoughtful decisions about curriculum focus and content versus emphasizing reduction in time (contact hours). Unfortunately, efforts to reform curricula by faculty-centered decision-making processes often fail due to entrenched turfdom or faculty reluctance to be critical of their colleagues. As a result, deans are often tempted to employ a draconian strategy by mandating an across-the-board reduction in clock hours that applies to all departments and all courses. Taxing departments equally is a relatively conflict-free decompression strategy that allows all departments to be equally unhappy and thus reduces curriculum warfare between departments (i.e., departments can direct their hostility toward the dean, not each other). However, this approach to decompression often does little to help dental schools make fundamental decisions about the philosophy and focus of their educational programs.
The critical question for leaders in dental schools is: how can schools make informed decisions about the focus and content of the curriculum without getting bogged down in divisive curriculum politics? Related questions include: What content should be discarded completely? What should be kept in the curriculum, but with reduced or different emphasis? What should be kept as is? And what areas should be expanded? Dental faculty experienced in curriculum planning know that these decisions are often conceptualized in terms of "our turf" versus "their turf" leading to Balkanization of positions and accompanying loss of perspective.
Respondents to the survey reported in this article and respondents to previous surveys about the process of curricular change describe the tortuous and emotionally laden path to educational reform, especially when it is pitched as "modernization."11–13 In our experience, the following statement sums up the typical reaction of the faculty to a modernization message: "If you’re asking us to modernize, you must be telling us that we are outdated. Oh yeah? Says who?" Providing an answer for the "says who" question is critical to building a curriculum that meets the current and future health care needs of the public and the training needs of dentists who provide these health care services. One strategy to answer the "says who" question is to provide an external standard, or benchmark, against which curriculum content and areas of emphasis can be compared.14 The goal of using an external standard is to move the discussion of what should be learned by our students beyond the "us versus them" logjam toward the question: how can we make the best informed decisions about preparing our students for entry into professional practice? Four strategies for answering the "says who" question are described in the following section: 1) curriculum prioritization hierarchies, 2) future forecasting, 3) review of curriculum advocacy in the literature, and 4) the ideal curriculum committee.
Curriculum Prioritization Hierarchies.
For more than thirty years, the World Health Organization has advocated that curriculum content and time should be prioritized according to a hierarchy where health problems that contribute most profoundly to public morbidity and mortality are addressed the most aggressively in the curriculum.15 In other words, diseases, environmental conditions, sources of injuries, and high-risk health-related behaviors that represent the most widespread threat to the overall health of society should receive the most attention in the curriculum. Although the WHO model has undergone many tweaks over the decades, the fundamental hierarchy has seven layers: 1) diseases, environmental conditions, sources of injuries, and high-risk behaviors that are direct causes of mortality, in order of incidence, within the scope of care of a particular health care discipline; 2) diseases, conditions, injuries, and behaviors that contribute to chronic, long-term morbidity and loss of function (in order of incidence); 3) knowledge and skills that health care providers need to perform assessment, prevention, and educational services within their scope of responsibilities; 4) acute but short-term or self-resolving illness that do not typically produce significant mortality or long-term disability; 5) special services needed for underserved populations and other populations with specific needs; 6) health care services primarily designed for improvement of quality of life; and 7) health care services primarily designed for improvement of personal appearance.
The Healthy People 2010 report can also be used as a source of information to create a prioritization hierarchy specific to oral health. Healthy People 2010 contains eighteen specific oral health objectives under the general oral health goal of "to prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services."16 These oral health objectives are listed in order of societal health impact in a hierarchy roughly similar to the WHO system starting with "deaths from oral and pharyngeal cancer" followed by untreated dental decay, permanent tooth loss, destructive periodontal disease, early detection of oral and pharyngeal cancer, and prevention by application of dental sealants among some of the priority items.
Future Forecasting.
The Delphi Technique is used to ensure that academic programs are future-oriented and "on the cutting edge" in relation to public needs and the advance of science.17 During a curriculum delphi process, experts who represent all facets of the profession forecast new competencies that practitioners will need to respond to the public’s health needs and service expectations in the future. The delphi method is conducted by mail or email so the panelists do not meet face-to-face. This is done so that force of personality does not come into play in the forecasting process. The initial set of forecasts is tabulated and distributed to the panel members who rank-order the items and add others not initially proposed. This process is repeated several times with each successive round depending on responses from the previous round. Consensus on item priority is usually reached after three to four rounds, and the results can then be fed to a task force charged with developing strategies to introduce new cutting-edge competencies into the curriculum.
Review of Curriculum Advocacy Recommendations in the Literature.
Comparing the curriculum to recommendations for educational priorities that appear in the literature is another way to provide an external standard that can encourage faculty to focus on the schools’ overall graduating "product." This can be accomplished by conducting a scan of the curriculum advocacy literature. The first step is to identify journals devoted to educational strategies pertinent to the profession or that routinely include articles and commentaries on educational issues. The second step is to tabulate the number of articles, typically going back three to five years, where the authors argue for inclusion or expansion of specific topics, issues, and activities in the curriculum. For example, over the past three years, fifty-three topics have been the subject of curriculum advocacy articles published in the Journal of Dental Education. The list below indicates the top ten topics and issues advocated by the authors of these articles for inclusion or increased emphasis in the dental school curriculum. The number of advocacy articles is indicated in parentheses.
Ideal Curriculum Committee (ICC).
Departmental autonomy, faculty comfort with existing routines, and reluctance to criticize colleagues can block efforts to revise the curriculum via peer review strategies, particularly when fundamental redirection is indicated. In this situation, using the ideal curriculum committee strategy may help focus attention on analyzing the merits of a new model of education, divert attention away from defending "the way we’ve always done it," and provide a structure for managing curriculum revision with sensitivity to organizational, political, and communication issues.18
How does an ICC work? Prior to the formation of the ICC, a broad-based faculty committee identifies curriculum problems that require more than transient "band-aid" solutions. Using this report as a catalyst, the dean appoints an interdisciplinary committee of respected teachers, well recognized for their ability to see beyond discipline-based boundaries, to develop an "ideal" curriculum model that will alleviate recognized educational problems and provide a new direction for the school. Sometimes, ICC members are nominated by the faculty, and this group also includes community practitioners and students. The goal of the ICC is to break the "we win, you lose" mindset by providing all constituencies in the dental school with a new curriculum model that is not closely linked to the philosophy of any one department or influential opinion-leaders among the faculty. The ICC model should be a comprehensive multiyear plan that can be reviewed as a single entity rather than a series of system tweaks (situation-specific fixes). This model is presented to departments for review, and schoolwide faculty forums are conducted to explain the plan and elicit suggestions. Feedback from these reviews is incorporated to produce a refined version that is unveiled at a schoolwide retreat for further debate. After modifications stimulated by the schoolwide retreat, the ICC plan is then sent through the school’s educational decision-making hierarchy for consideration, modification, and approval. Ideally, the unveiling of an ideal curriculum model and the ensuing debate about its merits will energize faculty and students and focus attention on the big picture question: what is the best way to prepare our students for entry into the world of dental practice?
In addition to decompression and strategies for approaching this formidable task, a second notable survey finding is that problem-based learning (PBL) is not perceived to be a viable curriculum format for dental schools, or at least schools have not been able to implement it. Only three schools (5 percent) reported that PBL was their primary curriculum format. However, schools that employ a PBL format continue to report positive outcomes about their programs.8,19,20 Among survey respondents, case-related (CRL) or case-supported teaching is used more than PBL, with 36 percent of the responding schools reporting "some courses use CRL for entire course; however, most are lecture-based." In addition, an interdisciplinary or thematically organized curriculum does not appear to be a curriculum model that can be easily implemented in dental school. Only four schools reported that their curriculum was organized around themes of interrelated topics. Adoption of a PBL structure and breaking down traditional departmental barriers to create an interdisciplinary curriculum are undoubtedly among the most challenging curriculum changes that can be attempted and are likely to be met with the resistance previously described.
As we think about other generalizations that could be made about the current state of the clinical curriculum at the majority of responding schools, the timing of clinical experiences, the structure of clinical practice models, and the incorporation of community-based activities must be considered. It appears to be a high priority at many schools to expose students to patients’ oral health needs and systemic medical problems early in the curriculum (84 percent of schools). Also, if we look at items already incorporated into responding schools’ curriculum in the past three years, nearly 70 percent reported creating a substantial comprehensive care experience in the senior year, and 52 percent reported that they had established group practice teams in the clinic. Much has been written about how these models can facilitate patient-centered care21 and lead to increased productivity.22 However, according to some of the respondents, these models have been in place so long that they did not consider them recent innovations. Finally, a majority of schools are requiring students to provide community-based patient care.
The most often selected curricular innovation already incorporated into the curriculum in the past three years was "increased use of computer-based technology" (86 percent of schools). In looking at what is planned for the next three years by responding schools, 82 percent projected an increased use of computer-based technology. While the focus on computer-based technology stood out, a separate question about distance learning revealed that few schools have incorporated off-campus learning capacity into their programs during the last three years (5.4 percent), and a modest 10.7 percent identified "providing distance learning opportunities" as a curricular innovation they were planning in the next three years. These findings showing limited interest in distance learning are in contrast to survey data recently reported by Andrews and Demps.23
Some of the most surprising responses to the survey questions related to faculty vacancies and whether faculty shortages will require that the curriculum be restructured. While 75 percent of the respondents reported that there were at least three faculty vacancies at their schools, when asked whether the respondents envisioned a need to restructure the dental curriculum in the short term because of faculty shortages, 90 percent of them answered "no." In a review of data from ADEA’s 2001–02 survey of vacant budgeted faculty positions,24 approximately one out of four dental schools actually has ten or more vacancies, with the prospects for decreasing vacancies gloomy. It will be interesting to see if the optimistic response about the relationship between the need for curricular restructuring and faculty vacancies will change as shortages are projected to increase.
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Conclusions |
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with two notable exceptions: interdisciplinary curriculum organization and use of problem-based learning. Approximately two-thirds of the respondents of this survey defined their current curriculum organization and presentation as largely discipline-based with a few interdisciplinary courses. While some schools reported that they used PBL and CRL in certain areas of the curriculum, only three schools (5 percent) indicated that all of their courses used the PBL format. Regarding integration of major sections of the curriculum, a very low percentage (7 percent) reported that their entire curriculum was organized around themes of interrelated topics. The overwhelming majority of responding schools reported that their students had required community-based clinical treatment experiences. While a high percentage of the responding schools had at least three vacant faculty positions, nearly all reported that they did not envision a need to restructure the dental curriculum because of faculty shortages. The results of this study help to broadly describe the current structure and format of the dental curriculum at North American dental institutions.
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Acknowledgments |
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REFERENCES |
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R. D. DeBate and L. A. Tedesco Increasing dentists' capacity for secondary prevention of eating disorders: identification of training, network, and professional contingencies. J Dent Educ., October 1, 2006; 70(10): 1066 - 1075. [Abstract] [Full Text] [PDF]
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R. B. Donoff It is time for a new gies report. J Dent Educ., August 1, 2006; 70(8): 809 - 819. [Full Text] [PDF]
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E. Bernabe, J. B. Bernal, and R. J. Beltran-Neira A model of dental public health teaching at the undergraduate level in peru. J Dent Educ., August 1, 2006; 70(8): 875 - 883. [Abstract] [Full Text] [PDF]
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E. Solomon, J. Murray, W. W. Dodge, S. W. Redding, J. A. Valenza, C. M. Flaitz, J. S. Cole, and K. L. Kalkwarf Scope of practice comparison: a tool for curriculum decision making. J Dent Educ., March 1, 2006; 70(3): 231 - 245. [Abstract] [Full Text] [PDF]
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V. L. Patel, J. F. Arocha, S. Chaudhari, D. R. Karlin, and D. J. Briedis Knowledge Integration and Reasoning as a Function of Instruction in a Hybrid Medical Curriculum J Dent Educ., November 1, 2005; 69(11): 1186 - 1211. [Abstract] [Full Text] [PDF]
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K. L. Kalkwarf, N. K. Haden, and R. W. Valachovic ADEA Commission on Change and Innovation in Dental Education J Dent Educ., October 1, 2005; 69(10): 1085 - 1087. [Full Text] [PDF]
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S. K. Rich, R. G. Keim, and C. F. Shuler Problem-Based Learning Versus a Traditional Educational Methodology: A Comparison of Preclinical and Clinical Periodontics Performance J Dent Educ., June 1, 2005; 69(6): 649 - 662. [Abstract] [Full Text] [PDF]
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D. P. DePaola and H. C. Slavkin Reforming Dental Health Professions Education: A White Paper J Dent Educ., November 1, 2004; 68(11): 1139 - 1150. [Abstract] [Full Text] [PDF]
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W. D. Hendricson, F. Panagakos, E. Eisenberg, J. McDonald, G. Guest, P. Jones, L. Johnson, and L. Cintron Electronic Curriculum Implementation at North American Dental Schools J Dent Educ., October 1, 2004; 68(10): 1041 - 1057. [Abstract] [Full Text] [PDF]
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