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Critical Issues in Dental Education |
Key words: curriculum change, innovation, active learning
Submitted for publication 07/15/07; accepted 12/06/07
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Abstract |
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 TopAuthor information Abstract Institutional readinessPrinciples for changeConclusionReferences |
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The Case School of Dental Medicine began planning an innovative approach to curriculum change in 2002 as this national conversation was beginning. This article will chronicle the steps that the faculty took to vision, plan, and implement its approach and the factors that contributed to the school’s ability to undertake this transformational change.
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Institutional Readiness |
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TopAuthor informationAbstractInstitutional readinessPrinciples for changeConclusionReferences |
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For the Case School of Dental Medicine, many factors contributed to the readiness for change, but timing was a key factor. (See Table 1
.) The school’s previous crises in the early 1990s had been successfully overcome, and the school had just finished a successful accreditation site visit after a number of serious challenges had been noted seven years previously. This success marked the first time in the school’s recent history when consideration of innovation and change could have occurred, both because of recent program growth and stability and because the faculty had experienced an early pilot innovation project that exceeded expectations and could build upon that experience. This timing also provided a seven-year time period in which change could be implemented, outcomes assessed, and additional modifications instituted before another accreditation cycle. In other words, this hiatus allowed for the school to be sure that any changes were properly implemented with necessary documentation.
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A new strategic plan approved by the faculty included creative elements as part of the usual missions of scholarship, research, teaching, and service. Curriculum innovation was a goal of the educational mission adopted by the faculty, creating a culture supporting responsible risk-taking to achieve new growth. With action steps identified for achieving a curriculum approach, the foundation for change was established. The faculty determined that a far-reaching, comprehensive approach was required to have the desired effect. The changes considered could not be unidimensional, as a complex educational program requires a complex approach to achieve intended outcomes.
The school was also in a period of growth with the re-establishment of its core values that were aligned with the mission of the university. This was facilitated by the creation of a focused research program that re-established the Department of Biological Sciences and contributed to the development of new knowledge. It was an essential core element. As programs reflect on their mission, it has been emphatically stated that dental schools must preserve the profession as a learned one rather than simply permitting it to become a vocational endeavor.11 To this end, dental schools must consider their research mission and how scholarship is defined, fostered, and rewarded.11,12
Key hires were essential to the school’s ability to accommodate change. This included the aforementioned research revitalization at Case, with an influx of research faculty at the school to re-establish its research mission. Concomitant with this growth came opportunities to hire new faculty into key positions, including department chairs and junior faculty. Today, the school has twice as many full-time faculty members as it had in 1991. As potential faculty members were interviewed, they were informed of the change mission of the school in order to notify them and to establish a philosophical framework that both the school and the candidates could discuss and potentially come to a consensus on. This resulted in a cadre of faculty, both new and current faculty, who saw changing the curriculum as a common, worthwhile goal with reasonable expectations over the ensuing three- to five-year period. As management expert Jim Collins says, "it is essential to have the right people on the bus in order to advance organizations."13 The development of an adequate culture for change, including articulating a vision that the faculty could and wanted to rally around, was essential.
The revitalization of the school over the last ten years has been key to providing an environment conducive to change. Environmental factors in health professions schools and in health care in general have recently been highlighted as essential for consideration of change.14,15 Funding, expectations of faculty experiencing programmatic change, philosophical underpinning, faculty development, and workload are components that must be evaluated for readiness for change.14–18 Without them, change efforts would likely be unsustainable or unaccepted by those who could implement the change. Collectively, the plan for fiscal responsibility and strategically guided operation, research program, and faculty resource growth, as well as alumni and stakeholder support, contributed to the development of an environment that permitted consideration of a comprehensive curriculum change project.
Important in the school’s decision to change its curriculum were recent experiences with unique small demonstration projects. This experience gave the faculty an opportunity to create a different type of curriculum project that was limited in scope yet very distinctive from the typical curriculum project. The actual program could be scrutinized, not just a theoretical model. The school developed an innovative dental outreach program in the first year that provided students the opportunity to place dental sealants in the Cleveland Municipal Public School district, the poorest district in the state.19 This project was a completely new approach that required the faculty to wrestle with the idea of whether we could prepare first-semester, first-year students to place dental sealants in this setting. It was an opportunity for the faculty to assign significant portions of the curriculum early in a student’s career, to create an active learning environment through service-learning, and to create just-in-time learning that culminates in an intense clinical experience that improves health. Students’ schedules are cleared of all other academic responsibility during the time dedicated to the sealant program, thereby intensifying the experience. This experience has created the desired situation of deep, reflective learning for our students, while leading to slight anxiety about the experience. Outcomes of this initial project have been highly successful, leading to increased student satisfaction, reflection,19 and permanent external funding for the project. This project was the foundation for a particularly innovative component of the curriculum, the ACEs (A Cornerstone Experience) program. The ACEs Program is a critical piece of the curriculum that has a variety of model projects designed at key points throughout the four years. These serve as highlights in experiential learning that are supported by key curricular concepts in focused content areas. This program is meant to challenge the students’ knowledge, skills, and thinking as they experience new clinical encounters with simulated and real patients or evaluate other simulated or real situations experienced in the course of general dental practice (see Table 2).
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Each of the above factors contributed to the school’s ability to prepare for change and be ready and willing to do so. Coincident to our accreditation site visit was the opportunity to plan for a service-learning project (Healthy Smiles Sealant Program), which would take our students into a local school district to provide sealants and education. While that project was being planned at the departmental level, the faculty as a whole separately considered which dental students should be included in this project as it would mean students would rotate out of the school for the experience. For a year, the faculty wrestled with deciding between third-year students, who certainly would have enough knowledge and skills to be effective in this project, and other students. It was a question of stretching outside of our usual thinking to make this project different. A turning point came when one faculty member suggested that we should send our first-year students out. That suggestion was a moment of faith that was ultimately supported by the administration of the school and the general faculty who voted to approve the project with Year 1 students; with that, we began our innovative approach to considering curriculum change. The dean supported the faculty decision requiring that planning oversight occur and that outcomes be evaluated. To that end, once implemented, a survey of students completing the course, as well as the usual course evaluation, was conducted. The outcomes of both course evaluations and the student surveys were overwhelmingly positive about this project: "The sealant program has rejuvenated the faculty to ‘think outside the box’ and expand experiential learning modules throughout the curriculum."19
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Principles for Change |
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TopAuthor informationAbstractInstitutional readinessPrinciples for changeConclusionReferences |
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With an institutional environment for change that was conducive to new ideas, the faculty wisely began the curriculum planning process by asking a key question: "What should the dentist of 2010 and beyond look like?" Through an iterative process at a faculty retreat, groups of faculty considered this question. At the end of the session, each faculty member voted on (dot labeling) his or her five most important characteristics from among all the qualities on all lists. This initial consideration led to the development of the Case School of Dental Medicine’s principles for change document. These principles were modified through further faculty discussions at regular faculty meetings. As key components of the new curriculum were identified by the faculty, they were incorporated into a draft document of principles for change. The draft document was returned to the faculty for discussion, modifications, and, finally, ratification. The principles have guided the planning process since its inception and have served as an initial outcome assessment tool as we evaluate the outcomes of the change (see Table 3). The school holds two annual faculty retreats at which nearly all faculty attend a one and a half day session on important issues facing the school. Faculty decisions occur at the retreats as well as at general faculty meetings held at other times. All decisions within faculty purview are made by vote of the faculty in sessions in which a quorum is present.
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The School of Dental Medicine began outlining the principles for its new curriculum. The acronym "REAL" is the rubric. Creating Relevant, Experiential, Active Learning in a humanistic environment was the description of the task. Rajan has discussed the issue of relevancy in medical education, stating that "students expect to learn how to treat patients when they arrive, yet spend two years in lecture halls with endless PowerPoint presentations by a parade of professors."20 Relevance means not only the relationship between science and clinical care, but also that appropriate topics are valued with an appropriate scope and concentration. It means, perhaps, taking a broader approach rather than a specialized approach by scientists focused on a narrowly defined aspect of health or pathology in order to integrate concepts. The School of Dental Medicine faculty considered the obligation we feel as owners of discipline-specific content. Do we feel that we have met our responsibility to our students when we tell them every detail and fact without regard to relevance or the amount of information a student can absorb? Have we considered the connection of basic and clinical science concepts that will help them make reasoned patient decisions? In the current curriculum, can we say that we have positively impacted their learning in such situations? Instead, the school has evaluated essential knowledge after a thorough review of the curriculum by content experts and the faculty at large to address this issue.
The faculty reflected on educational practice and looked to examples in European health education and other health professions education in the United States in determining that alternatives to passive learning formats may be educationally beneficial. Consultations with educators from medical and dental education helped to focus our approach to instruction that would balance the desire for experiential and active learning strategies with our faculty and physical plant resources. Experiential and active learning can be considered corollary constructs. Actively engaging students in their educational programs has long been espoused as an educationally superior method of learning. Kolb’s view requires integrative perspectives that combine experience, perception, cognition, and behavior with educational theories dating back to Piaget.21 To that end, the school has designed a curriculum that actively engages students in their learning through use of multiple educational formats and requires independent study in a hybrid delivery system. Because of faculty resource limitation, judicious use of small group learning was utilized. Instead, the faculty delivers the curriculum using a variety of learning formats such as small and medium group sessions, small group learning within the context of a large classroom (team-based learning), simulation, virtual reality simulation, and standardized patient simulation exercises, as well as traditional lecture courses. This variety allows the school to engage students actively, while functioning within our resource capabilities.
Use of cornerstone experiences (ACEs) grounds the curriculum at important stages in the students’ learning to engage them in novel, intense, clinical learning opportunities. Key curricular content was planned around the clinical experiences and has created the desired enlightening moments of insight for the students.
Creating curricular efficiencies in both medical and dental education has also been a concern of oversight groups and faculty. Efficiency in learning is a well-regarded concept as dental schools consider relevant content to include in their curricula. The Case School of Dental Medicine has utilized simulation technology to enhance learning efficiencies. Our studies of the DentSim technology that has been used in the first semester with first-year students revealed efficiency in learning eye-hand coordination while exposing students to a technological environment that they will face as practitioners in the future.22 Yet, concern about educational efficiency and the quality of education with regard to simulation has been expressed in medical education.23
As the faculty were defining the organization and boundaries of the curriculum and because of the first key question asked ("What does the dentist of 2010 need to know?"), priority issues emerged. The faculty recognized and acknowledged the essential elements of the program that needed to be preserved and expanded. First on the list was to preserve what we do well. The faculty values how the school has created its clinical training program. For over forty years, the school has featured comprehensive patient care, focused in students’ Years 3 and 4, as a hallmark of its education and service. New plans to expand this program to include vertical integration of all predoctoral students in what will become "group practices" were articulated. The group practices will include aspects of general practice dentistry and practice administration in a newly configured clinical setting. This will require major renovation of our comprehensive care clinics, a process that is currently being planned. Students are integrated into the group practices upon entrance to the program, participating at a level appropriate to their educational attainment and competency and functioning accordingly. For example, first-year students will assist Year 3 and 4 students. Second-year students will complete the dental recalls of the group practice and place restorations according to their competency achievement during their spring preclinical experiences. Third-year students will be engaged in comprehensive care, as will fourth-year students. Additionally, fourth-year students will take on practice management duties relevant to their group practice.
The faculty has redefined and reorganized its competency document to align with broad themes in the new curriculum. The document the school has been operating with since 2001 was reorganized according to the new curriculum frame rather than the original discipline-based domains. The Academic Affairs Office distributed the original educational objectives according to the new themes and added objectives that emerged from the Principles for Change document. The faculty as a whole approved, in principle, a "first pass" draft at a faculty retreat in 2005. While planning for the curriculum was occurring, a subcommittee of interested faculty reviewed the draft document and compared it to Commission on Dental Accreditation (CODA) Standards and reflected on its language, measurability of educational objectives, and faculty intention. Once the subcommittee was confident in the draft (after several meetings and revisions), the document went back to a general faculty meeting for discussion and approval with minor editing by vote of a quorum of full-time faculty.
All content in the curriculum is now defined by four themes and two threads. The themes are Health and Well-Being, Disease Processes, Restoration of Health, and Maintenance of Health. These four themes run across the four years of the program and encompass both newly organized content and courses that will remain as traditionally organized in the future. Likewise, woven throughout the four years are two highly regarded threads: Inquiry and Leadership. The faculty thought it of great importance to stress the value of science in the profession of dentistry in this program.11,17 Therefore, a new approach to the value and integration of science into all four years of the curriculum was deemed appropriate. These themes and threads cut across disciplines, facilitating collaboration among faculty that resulted in a more integrated presentation of the basic and clinical sciences content.
The genesis of the inquiry thread stems from the faculty’s desire to create a culture of inquiry within the school. If the curriculum approach includes new efficiencies, then having students gain skills in critical thinking, knowledge of evidence, evaluation of evidence, and clinical decision making would give them necessary tools for future practice. When students who have been trained in inquiry and critical thinking skills face novel problems in the future, they should be able to apply their knowledge in new ways to solve challenging contemporary problems. The integration of the curriculum across disciplines, active learning environments, and students’ responsibility for their learning provide a framework for this culture. It is also supported by an expanded student summer research program and the incorporation of a research ACE into the third-year curriculum.
To engage students more meaningfully in their courses, the faculty designed small group learning sessions and a variety of educational formats for that purpose. Requisite for this type of learning is time for student reflection and independent study. Therefore, two and a half days of independent study have become an essential component of the program. These are blocked in half-day segments to coincide with adequate time for discovery of knowledge relevant to the small group case sessions, which are scheduled on Mondays, Wednesdays, and Fridays for two hours per session. The half-days are necessarily spaced to accommodate learning. (See Table 4 for a typical weekly schedule in Year 1.) The faculty hold this time sacrosanct, and nothing compromises it because it is essential for this type of learning to be successful. Each of these factors may contribute to the development of critical thinking and the desire for continuous inquiry and lifelong learning across a dentist’s career.15,23
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In outlining relevant and essential curricula for the school, a critical evaluation of all content was undertaken. From the comments of our medical colleagues who serve jointly as faculty in our program to reports evaluating the direction that dental education should take for the future, the faculty knew that decompression of the program was important.4,6 A critical analysis of what is taught and what should be taught in the future was a major concern of the faculty during the summer of 2005. Each department defined essential curricular concepts, which were placed in a database through a series of curriculum workshops held during that summer. All faculty members then reviewed these for common themes across disciplines, and an organizational template of the new curriculum was developed. Concepts and educational objectives were placed into the template in order to develop the new integrated basic science educational modules termed EdMods. These new courses incorporate physiology, anatomy, histology, pathology, and biochemical processes into courses organized by organ systems in health and disease. It is important to note that parts of the curriculum have remained unchanged. To date, the majority of the change in the curriculum has occurred via integration of basic science courses in an organ-based approach to health and disease. The review of essential content facilitated isolation of independent study time.
Along with the decompression of the curriculum was an evaluation of modern knowledge that must be included in a curriculum that is relevant to a changing profession. That includes a critical review of topics such as developmental genetics, translational research, and technology in a contemporary program of study.
Finally, a new role for the faculty has been de-fined—that of mentor and coach rather than content expert. Although faculty remain experts in their field of study, the approach with students now is meant to abet learning for learning’s sake and to assist students in becoming the best that they individually can become. To enable transition to this new role in the curriculum, faculty development has been a requirement. As new educational strategies are being prepared, the faculty must be equipped with the appropriate knowledge, skills, and resources to successfully create and implement innovative programs. Partnership and support from the Ohio Dental Association were essential in creating the opportunity for faculty development for this curriculum project. A core group of faculty leaders was trained in small group facilitation at another institution and returned to train a cadre of facilitators at the school. Faculty training occurs primarily in the summer in one and a half day sessions that include theory, examples, and demonstrations of small group sessions. Faculty retraining and updating occur in December. Other faculty development workshops have included the topics of assessment for the new curriculum, case development, and curriculum planning. Consultants who are experts from dentistry and medicine in the United States and Canada have participated in the school’s faculty training and preparation for curriculum change.
As with any change, constituents are on board with varying degrees of enthusiasm. There were no faculty who openly opposed the prospect of transformative change. However, once the planning began, levels of engagement emerged. For some faculty, integrating their content expertise into collaborative courses means losing some measure of identity and perhaps influence. Likewise, changing educational formats to include small group learning has little pay-off for faculty who are acclaimed, respected lecturers who consistently garner teaching awards. For those faculty, this change has been challenging. Through the inclusion of all faculty in every step of the process, to the point of redundancy, every faculty member has been given the opportunity to have input into the processes from overall planning to course design. The school spent two and a half years accommodating process to ensure that the most faculty members would have input into the process (see Table 5). No change went forward without faculty approval. Despite this, several faculty members remain ambivalent about our changes. We continue to include them in the processes and have had a measure of success early on because of everyone’s contribution, whether enthusiastic or not. As such, the process once begun was from the bottom up. Extraordinary effort has been placed into our change efforts to date, to the credit of all faculty. This level of change, however, is not easy.
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Conclusion |
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TopAuthor informationAbstractInstitutional readinessPrinciples for changeConclusionReferences |
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The REAL curriculum at Case is not presented as a model of dental education, but as one organization’s approach to the faculty’s vision for dental education. Change for the sake of change is not appropriate, nor is it right for everyone. Changes such as these are not easy. Bertolami suggested that this is a time of change, challenge, and opportunity in our profession.25 Indeed, the faculty, staff, and students of the school would unanimously agree because, in the end, this is the right thing for us to do.
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Acknowledgments |
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Author Information |
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TopAuthor informationAbstractInstitutional readinessPrinciples for changeConclusionReferences |
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REFERENCES |
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TopAuthor informationAbstractInstitutional readinessPrinciples for changeConclusionReferences |
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This article has been cited by other articles:
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  H. Spallek, J. A. O'Donnell, and Y. I. J. Yoo Preparing Faculty Members for Significant Curricular Revisions in a School of Dental Medicine J Dent Educ., March 1, 2010; 74(3): 275 - 288. [Abstract] [Full Text] [PDF]
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M. A. Fisher, D. C. Beeson, and M. G. Hans Dental Practice Network of U.S. Dental Schools J Dent Educ., December 1, 2009; 73(12): 1387 - 1393. [Abstract] [Full Text] [PDF]
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A. Thind, K. A. Atchison, R. M. Andersen, T. T. Nakazono, and J. J. Gutierrez Reforming Dental Education: Faculty Members' Perceptions on the Continuation of Pipeline Program Changes J Dent Educ., December 1, 2008; 72(12): 1472 - 1480. [Abstract] [Full Text] [PDF]
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M. I. Ryder, P. Sargent, and D. Perry Evolution and Revolution: The Curriculum Reform Process at UCSF J Dent Educ., December 1, 2008; 72(12): 1516 - 1530. [Abstract] [Full Text] [PDF]
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G. Crain Managing Change in Dental Education: Is There a Method to the Madness? J Dent Educ., October 1, 2008; 72(10): 1100 - 1113. [Abstract] [Full Text] [PDF]
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