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Dental Education in Wuhan, China: Challenges and Changes

Key words: dental education, simulation, problem-based learning, curriculum, multimedia

Submitted for publication 10/20/05; accepted 11/29/06

	Abstract

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The aim of this article is to describe the innovations in the School of Stomatology at Wuhan University (WHUSS) that are likely to shape the future of dental education in the People’s Republic of China. There are forty dental schools in China; the five most well known are located in Beijing, Chengdu, Shanghai, Xi’an, and Wuhan. Although patient-centered, comprehensive care has been recommended as the future of dental education, traditional dental education in China still faces many challenges to accomplish this goal. WHUSS, one of the more progressive dental schools in China, has implemented several educational innovations to traditional dental education by restructuring the curriculum through the introduction of problem-based learning (PBL) and other strategies in clinical training. Although implementation of educational innovations is still at an early stage throughout China, it is reasonable to speculate that many schools will develop similar strategies as those developed at Wuhan to improve dental education during the next several years. However, additional research is necessary to evaluate the efficacy of such educational strategies and to determine the appropriate implementation of a contemporary dental curriculum and pedagogic methodology. The curriculum modifications that have been achieved to date as well as the existing challenges are discussed to provide the reader with an understanding of contemporary dental education in China.

Students in the People’s Republic of China who are interested in pursuing a career in dentistry must complete their primary and secondary school education. Potential candidates for admission must take the Standard Examination for University Admission (SEUA), which is administered annually throughout China. A student may apply to multiple dental schools. The minimum acceptable SEUA score may vary among different dental schools.

The National Ministry of Education operates an accreditation process for all dental schools. There is a national organization called the Stomatological Educational Committee, a branch of the Chinese Stomatological Association (CSA), which coordinates and monitors dental education in China.

Generally, five years are required to obtain a bachelor’s degree in stomatology (B.D.S.). Thirty to 40 percent of graduates have the opportunity to take the standardized Annual Entrance Examination in order to qualify for admission to a postgraduate program. A master of philosophy degree or professional degree is awarded after three years of study, completion of sufficient course credits, and successful defense of a thesis. Similarly, a doctor of philosophy is awarded after five years in residence in a related research program, acquisition of sufficient course credits, and a successful thesis defense. The remaining 60–70 percent of graduates choose to enter the job market to practice in dental clinics after completing the five-year B.D.S. But before they practice independently, they must take a national licensure examination as they do in the United States and other nations.²

Today, most dental schools in China have developed a joint professional master’s degree program, which articulates with the five-year B.D.S. program by offering a two-year advanced dental clinical training and basic research training program leading to a master’s degree. In the traditional five-year B.D.S. program, students take courses in biomedical sciences and general education during the first four semesters as in the medical school curriculum. During the next two semesters, students also take basic medical courses and obtain clinical medical training in hospitals affiliated with the medical school. The seventh and eighth semesters are devoted exclusively to dental education, and students begin their preclinical training. During the last year, students embark on their dental clinical training and subsequently participate in internships in dental hospitals, while one or two sessions per week are spent for lectures in the fifth year. The curriculum and course content in various dental schools in China are basically the same, and all use the same textbooks. However, students in China do not take board examinations during their dental education. Compared with students in the Western dental education system, dental students in China may receive a more extensive background in biomedical sciences and clinical medical skills, but they only begin to study dental subjects in the fourth year. Thus, they have only one year to acquire dental knowledge and one year of clinical training.

In the past, all educational fees (except for textbooks) were paid by the government. Starting in 1993, students attending schools of higher education were required to pay tuition; however, scholarships and government loans are readily available as occurs in Western nations.

After joining the World Trade Organization (WTO) and experiencing the recent rise in economic development, China has begun to recognize deficiencies in health care education, especially in dental education. Fortunately, the dental schools in China are generally aware of their need for continuing advancement by adopting innovations that are consistent with government reform and open policy. As a result of interaction with dental schools in other countries, new teaching and learning concepts and methodologies in Chinese schools are being adopted to meet the changing needs of dental students, the patients they will serve, and the evolving role of dental practitioners. The dental educational trend is to gradually incorporate the elements summarized by Majumder et al.³ as follows: education for capability; community orientation; self-directed/learner-centered learning; problem-based learning and task-based learning; integration and early clinical contact; continuing professional development; unity between education and practice; evidence-based medical education; and communication and information technology. Educational strategies such as problem-based learning, the development of seven-year master’s degree programs, use of bilingual instruction, multimedia (information technology), and simulation laboratories in preclinical training are being adopted in China.

	Transformation of the Dental Curriculum

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Due to shortcomings of the traditional training program for postgraduate education, which consisted of a five-year bachelor’s degree plus a three-year master’s degree, most of the dental schools in China are starting to implement the previously described seven-year graduate program (five-year B.D.S. plus two-year master’s degree) to reduce the time required to obtain the master’s degree. The seven-year graduate program was started in the West China College of Stomatology at Sichuan University in 1988. This program has been very successful and has stimulated other dental schools to follow this model.

Since no existing curriculum was accepted as a standard model for dental education in China prior to the 1980s, experienced members of a multinational academic staff were consulted to establish a modern and realistic dental curriculum to meet the country’s needs. The resulting seven-year dental curriculum is actually a fourteen-semester program, consisting of five phases. Course numbers, titles, and credit hours for years one through seven in a professional program are shown in Table 1 (see pages 307–8).

Furthermore, the student exchange program, which attracts a great deal of attention every year, operates between WHUSS and its cooperative schools scattered in America, Europe, and Asia. This program provides an opportunity for students to spend two months overseas to be exposed to more advanced dental concepts and techniques.

	Innovations in Dental Education

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To adapt to the challenges of a global economy and technology, diversification of educational strategies has become the major trend of current educational reform. As one of the most well-known dental schools in China, WHUSS has developed a diverse roadmap for dental education to keep the dental curriculum congruent with oral health needs in China in the twenty-first century. Strategies such as problem-based learning (PBL), multimedia education, simulation in preclinical training, and community-based dental education are included in this effort. A comparison of traditional and revised dental education strategies employed at WHUSS is presented in Table 2.

The PBL educational approach was first used in pediatric dentistry at WHUSS and subsequently expanded to other dental disciplines and other dental schools. A core of teachers was sent to McMaster University Medical School, Indiana University, and University of Hong Kong to receive training in PBL, and expansion of the tutorial program is under way. Only the teachers who have attended PBL training courses and passed the exams are certified as PBL tutors. Before starting the PBL program, all tutors get together to discuss PBL cases, teaching goals, related resources, curricular timetable, exhibition pattern, etc. In one school year, ten to twelve cases are discussed. These cases cover most professional learning issues, including ethical, legal, psychological, social, environmental, and cultural aspects. Normally a case involves three sessions: the first one is devoted to presenting the scenario, delivering part 1 of the case, and student self-learning after the session; the second session is devoted to discussing part 1 and delivering part 2 of the case, followed again by student self-learning; the third session is spent in discussing part 2 and delivering part 3 of the case, followed by a summary of the entire case and an evaluation of both the tutors’ and students’ performances in the procedure; finally the tutor provides a brief review of the case and evaluation. During the program, students take responsibility for identifying the important issues, demonstrating and communicating their opinions, collecting necessary information, and making decisions and plans. In the final ten minutes of each session, students assess their performance and the whole procedure of PBL and then make suggestions for further refinements of the PBL program.

At present, PBL is still at the infancy stage at WHUSS, and the ratio of PBL to traditional lecture-based classes is 1 to 4. Most of the students at WHUSS are very enthusiastic about the PBL approach in terms of cognitive, affective, and psycho-motor skills. They prefer this mode of learning over the traditional teaching program because they use the solution of clinical problems to learn dentistry in a dynamic and intellectually stimulating manner.

This approach enables integration between the basic and clinical sciences to enhance clinical reasoning and knowledge retention. Above all, PBL infuses a more real-life atmosphere into the learning process and is more enjoyable than conventional lecture-based instruction.⁶

Addition of Simulation to Preclinical Training
With the application of simulation strategies, dental schools have improved their preclinical training by providing a more realistic learning environment.⁷ Recent findings in cognitive psychology have further underlined the importance of simulations in the education of health professionals.⁸ Many skills and procedures in medicine can be only partially learned in the classroom. They must also be learned via chairside or hands-on experiences, which includes observing and shadowing a mentor. For the safety of patients, some necessary but potentially harmful procedures or skills need to be developed and tested as much as possible via simulation before applying them to actual patients.⁹ As technology has evolved, simulations have become more sophisticated, but their role has remained unchanged in that they help students to develop and test specific diagnostic and therapeutic skills. Simulations not only offer more opportunity for students to practice skills, but also improve students’ performance on technical skills, which is an important educational outcome.

The KavoDESplus5192 simulation system, an experiential learning tool that imitates "real life" clinical conditions in dentistry, has been introduced at Wuhan School of Stomatology. This simulation manikin device permits the movement of some of the patients’ parts, such as head, jaws, and teeth, as well as the opening and closing of the mandible. This allows students to prepare and fill cavities, design dentures, prepare abutment teeth before fitting a denture, and much more. Multiple disciplines can be involved in manikin training, which is similar to the treatment of clinical patients. With the help of simulator manikins, students can learn to position the chair back during treatment and to master hand fulcrums and operate the odontoscope used in treatment. Through this form of practice, students feel much more confident and better prepared for the clinical environment. The preclinical or laboratory component of dental education using Kavo simulators seems to have incomparable advantages over traditional education in graduating dentists with superior technical skills. However, more empirical research is needed to support this claim.

Adopting Community-Based Dental Education
The traditional curriculum has been faced with increasing inadequacies in the training of competent graduates to meet the health care needs of the public. After graduation, dental students will face diverse groups of people and thus diverse oral health care needs. Consequently, formal instruction is essential to train students how to communicate with their patients. The reconfiguration of the curriculum should meet the needs of a changing world. Some dental schools in China have integrated community-based education into their curricula, and dental screening and prevention programs in elementary schools and kindergartens are also included in this program. WHUSS was the first to develop community-based dental education in China.

This type of experimental learning in communities or schools can help students improve their skills in dealing with patients’ needs and delivering efficient oral care. The program integrates behavioral and population-based sciences and exposes students to social, environmental, and cultural influences that affect health and diseases.¹⁰ The experience of community-based dental education can broaden and deepen students’ social skills, stimulate their creativity and self-confidence, offer first-hand patient information, and provide the opportunity to experience clinical situations in real-life settings.

Community-based dental education holds promise as an educational strategy to facilitate the personal and professional development of future dentists through reflective processes.¹¹ In this program, many community sites were examined to meet the requirements of the curriculum, including native Chinese health clinics, community clinics, health centers, and some government authorities. Dental clinics were set up in primary schools where students can provide public dental services and advice. Differences and commonalities of community settings are taken into account in developing, implementing, or revising clerkship programs for the students with their interests and previous clinical experiences in mind before assigning them to a community site.¹² Community-based experience improves the dental student’s understanding of the relationship of oral health determinants between individual patients and society. Through innovation, dedication, and compassion, it also helps students enhance their self-awareness, self-confidence, self-motivation, and self-discipline.

Using Multimedia in Dental Education
A disadvantage of traditional preclinical laboratory teaching is that students have difficulty integrating theoretical knowledge and practical skills, which can result in knowledge fragmentation. Multimedia applications may help fill these gaps by replicating clinical situations and simulating biological events.¹³ Modern educational theory coupled with multimedia application and a desire to be generally more accountable has led to radical changes in the way in which dental education is now delivered. Nowadays, almost all courses in the top five schools in China are taught with multimedia. Multimedia packages of audio, DVDs, and CD-ROM materials all present opportunities to demonstrate the art of teaching in action.

Today’s technology allows educators to design and create tools that enable teachers and students to work with material from different sources and to attend courses at various sites. The personal computer represents perhaps the greatest boon to this movement by providing a vehicle for user-friendly, interactive, multimedia courseware.

Multimedia technology provides a teaching environment where reality, communication, knowledge, and interest are in harmony. The modules can provide the opportunity to develop and consolidate the concepts of integrated patient care and allow interactive learning in a nonthreatening environment. In particular, learning outcomes can address history-taking, examination, diagnosis, and treatment planning skills; integration of theoretical and practical aspects of case management; and relevance of medical conditions to oral health and treatment planning. Literature¹⁴ in education psychology indicates that good interactive multimedia teaching modules may provide intellectual stimulation with immediate feedback for students. Interactivity will engage students in active learning; students can have maximum control within the module, and the design should include user-friendly features.¹⁵ For example, multimedia education used in the subject of oral and maxillofacial radiology in our school is very different from the traditional classes in which a teacher or an instructor didactically demonstrates the radiological techniques to the students. The multimedia approach, which uses computer projection equipment as the major tool and applies diverse software, directly demonstrates the imaging principles of X-radiation, CT, and MRI. Techniques, procedures, and characteristics of these images can be effectively presented using strategies such as flash audio and video to facilitate learning. This method of instruction can be pedagogically enjoyable and visually stimulating, while enhancing knowledge retention.

Besides multimedia, other modes of technologically based learning have also been introduced into dental education for teaching and learning, such as web-based learning. Internet resources are now commonly used as educational tools in the medical sciences.^16,17 High potential for information diffusion, including texts, images, videos, and animations, are some of the advantages of this new way of communication in the educational system. The use of online delivery of content and information has a bright future in dental education.¹⁸ Learners at WHUSS can acquire data they need easily through the university library, which is linked to other libraries for optimal resource sharing.

	Summary

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Examining core educational values is the first and most important step during the process of modernizing existing Chinese dental education by incorporating new methods of teaching and learning. In China and other nations, numerous attempts have been made to modify course design and other curricular aspects of dental education in the past, but these efforts have often met with strong resistance. The educational system cannot remain stagnant; it is necessary to evolve in order to meet changing societal needs.

Many obstacles exist as dental education reform is initiated in China. These barriers includes dormant leadership, lack of expertise in curriculum planning, inadequate financial resources, lack of management skills, and most important of all, the mindset of the faculty toward change from the traditional ways of doing things. Considering the nation of China as a whole, programs in educational reform are still in their infancy, but it is reasonable to speculate that many schools will follow the lead of Wuhan University and develop innovative programs to improve dental education in China over the next several years. Additional research is now necessary to monitor and evaluate the outcomes of these new innovations in dental educational programs in China and determine the ideal dental curriculum that provides the most optimal learning environment for students and demonstrates the best learning outcomes.

	Acknowledgments

 
We appreciate the generous funding from the School of Stomatology of Wuhan University to make this work possible. We are grateful to our partners and all students and tutors who took part in completing this report that describes curriculum innovations under way at this dental school and in other schools throughout China.

	Footnotes

 
Dr. Huang is Associate Professor, Department of Prosthodontics, School and Hospital of Stomatology, Wuhan University; Dr. Bian is Dean, School and Hospital of Stomatology, Wuhan University and Director, Key Lab for Oral Biomedical Engineering of Ministry of Education, People’s Republic of China; Dr. Tai is Director, Department of Preventive Dentistry, School and Hospital of Stomatology, Wuhan University; Dr. Fan is Vice President, Chinese Stomatology Association and Emeritus Dean, School and Hospital of Stomatology, Wuhan University; and Dr. Chiu-Yin is with the Department of Medicine and Center for Faculty Development, China Medical University, Taichung. Direct correspondence and requests for reprints to Dr. Zhuan Bian, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, Hubei, People’s Republic of China 430079; 027-87647443 phone; kqyywjtx{at}public.wh.hb.cn.

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