J Dent Educ. 72(9): 1067-1076 2008
© 2008 American Dental Education Association
Development of an Interdisciplinary Course in Information Resources and Evidence-Based Dentistry
Alan E. Levine, Ph.D., M.Ed.;
Richard D. Bebermeyer, D.D.S.;
Jung-Wei Chen, D.D.S., Ph.D.;
Dell Davis, M.S.I.S.;
Carolyn Harty, R.N., M.L.S.
Key words: evidence-based dentistry, critical appraisal, dental informatics, dental education, dental students, library resources, information technology
Submitted for publication 01/30/08;
accepted 04/25/08
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Abstract
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The capacity to locate, access, and appraise information is an important skill required for success in dental school and beyond. An interdisciplinary course was implemented to teach first-year dental students at the University of Texas Health Science Center at Houston Dental Branch about evidence-based dentistry, search strategies, critical appraisal of the literature, and dental informatics. Students learned to develop a clinical question, conduct a search to find answers to that question, and critically appraise one of the retrieved resources. Over a period of four years, a total of 259 dental students completed a questionnaire that requested their assessment of this course. Seventy-five percent of the respondents agreed or strongly agreed that they learned to effectively search databases such as the Cochrane Collaboration and PubMed and to critically appraise websites and journal articles and that the information on evidence-based dentistry and critical thinking skills was valuable. In response to open-ended questions, approximately 35 percent of the respondents mentioned the importance of learning to search PubMed and Cochrane databases. Approximately 20 percent of the respondents felt the course did not contain new information. These results indicated the effectiveness of the course in familiarizing the students with the capacity of online resources to help them locate, access, and appraise information pertinent to oral health issues and the practice of dentistry. A future goal is to integrate information and skills associated with evidence-based practice into other courses in the dental curriculum.
Information technology has become an important tool in all aspects of health care including dentistry. These advances have accelerated progress in areas leading to improved diagnosis, patient care and management, and basic and applied research. The importance of this area to dental education is recognized by the establishment of accreditation standards for dental education programs by the Commission on Dental Accreditation (CODA) of the American Dental Association (ADA). The dental graduate is required to be competent in the area of "Information Management and Critical Thinking." Specifically, the graduate must be able to "use critical thinking and problem solving related to the comprehensive care of patients" and to "use information technology resources in contemporary dental practice." To achieve these competencies, it is important for the student to progress from being a dependent to an independent learner.1 Chiappelli et al.2 in a 2003 editorial pointed out that most dental schools did not include the skills or tools of evidence-based dentistry in their curricula. These authors advocated stressing the ability to filter the dental research literature to identify the "best available" evidence and pointed out that evidence-based dentistry is a paradigm for the practice of dentistry in the future. Future dental practice requires knowledge of evidence-based dentistry (EBD), the ability to conduct critical appraisals, and the ability to analyze and apply knowledge in clinical situations. EBD was defined by the ADA as an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.3
Dentists must be knowledgeable about and keep up with the latest developments to make informed choices to improve patient care.4,5 To achieve this goal, the student must be able to make appropriate use of current information technology to solve dental problems. Dentists must be clinically effective; i.e., they must ensure that their specific clinical interventions, when implemented for a particular patient or population, do what they are intended to do—improve and maintain health and achieve the greatest possible health gain from the available resources.6 This requires that the student obtain adequate training because students are often not as knowledgeable in the area of computer literacy and critical thinking as is perceived. For example, a study by Mattheos et al. found that the computer skills of European dental students and educators were not as sophisticated as often perceived through self-assessment.7 Students are often very familiar with Internet search tools8 such as Google and Yahoo, but do not know how to obtain high-level scientific evidence using PubMed or the Cochrane Collaboration. The lack of adequate knowledge of literature search skills among professional school students may not be surprising. A study of undergraduates at the University of Central Michigan indicated that while the majority of students rated their research skills as good or excellent, many of them lacked the ability to conduct advanced searches, appraise the trustworthiness of resources, and differentiate among different types of resources.9 The Internet is not designed for efficient retrieval of scientific information, and it is therefore important to learn how to access preferred databases to retrieve the best information in a timely manner.10 Advances in search engines such as Google Scholar allow retrieval of higher level information, but they are still somewhat limited compared to PubMed and the Cochrane Collaboration. A distinct advantage of PubMed and the Cochrane Collaboration is the ability to search with a standardized vocabulary of medical subject headings (MeSH) and the ability to limit the search to "clinical trials," for example, in addition to searching by key words only.
Many communication and information technology applications are associated with quality dentist-patient relationships and promote communication, interpersonal treatment and support, contextual knowledge of the patient, and trust.11 These skills can positively affect the character of the dentist-patient relationship. Having adequate training in information searching skills will increase the use of the available electronic resources.12 Hilty et al.13 concluded that applying computer technology to education and clinical care is a key step in computer literacy for physicians. Uribe and Marino14 found that although 88 percent of dental students searched the Internet, only 21 percent used it to find dental information related to their studies.
Given the advances in computer technology and health care, including dentistry, it is important that these information management breakthroughs are communicated to students during the dental school curriculum. Specifically, the content of the dental school curriculum should be based on the principles of evidence-based inquiry.1 Designing a curriculum based on evidence-based inquiry and incorporating computer literacy, knowledge of advanced searching skills, evidence-based dentistry, and the ability to critically appraise resources can be difficult. A study of a curriculum revision at the University of Florida concluded that there was a need to raise faculty awareness of the importance of acquiring evidence-based educational skills.15 Silk et al.16 described an approach used in a third-year family medicine clerkship that incorporated a conceptual model into the teaching process. This process, known by the acronym "PEARL" (Preplanned search intervention, Execute the search, Allow students to share their results, Review the quality of the evidence, and discuss Lessons learned from the search), encompasses the knowledge and skills required for this clerkship and helped students learn how to apply the concepts they acquired through the PEARL process. Finkel et al. reported that a mandatory course in evidence-based medicine was enthusiastically received by first-year medical students as judged by information gathered through informal inquiries but not a formal evaluation.17 Finkel et al. stressed the importance of providing training in evidence-based inquiry before students began their primary care clerkships that utilize evidence-based medicine techniques.
While stand-alone instruction in evidence-based medicine improved learners’ knowledge in order to achieve improvement in measured outcomes, moving the information into the clinic improved their skills, attitudes, and behaviors.18 Similar results were reported by Frasca et al.,19 suggesting that instruction during clinical years allows medical students to better learn and assimilate critical appraisal skills. The New York University College of Dentistry20 has developed a four-year curriculum to teach critical thinking skills, which begins with three courses teaching information technology, epidemiology, and critical thinking in dentistry and a "Skills in Assessing the Professional Literature (SAPL)" course. This is followed by utilization of these skills throughout the curriculum with additional seminars and case conferences. Likewise, results of a study of medical and nurse practitioner students in Oregon indicated that it is important to evaluate not only the searching ability of the student but also the ability to use the resulting information.21 In an attempt to better evaluate the competence of medical students in evidence-based medicine, a computer-based objective structured clinical examination (OSCE) station was developed and used to show the importance of being able to both select appropriate resources and apply them to specific clinical situations.22 The importance of critical thinking skills was also indicated by the correlation of scores on the California Critical Thinking Skills Test (CCTST) and scores on the National Board Dental Hygiene Examination.23 A controlled trial involving third-year osteopathic medical students in an obstetrics and gynecology clinical clerkship indicated that the teaching of critical appraisal was effective in increasing the ability of these students to utilize evidence-based medicine.24
However, the value of teaching health care students or practitioners to search the literature does not always lead to measurable outcomes. A systematic literature review of studies done mostly in U.S. medical schools concluded that there was only limited evidence to show that information skills training improved patient care.25 In addition, Badgett et al.26 found in a study of third-year medical students that interventions providing instruction in searching did not increase the frequency of searching or satisfaction with the search. It is still an open question as to the effects of evidence-based approaches to the practice of health care. Further high level studies and the identification of appropriate outcomes are needed to definitively answer this question.
The use of an interdisciplinary approach to teach information-searching skills and critical appraisal has been shown to be effective in many instances. An interdisciplinary educational approach was taken in a graduate biomedical and health informatics curriculum, and program evaluations indicated that this strategy was perceived to be innovative and reflected the needs of health care.27 A multidisciplinary course was shown to be effective in teaching library and critical appraisal skills to students in a third-year medical clerkship at the University of Illinois College of Medicine.19 In this study, students’ learning needs were better addressed by teaching library skills as a tool to reach a goal rather than as an end unto themselves. This was facilitated by the provision of coordinated instruction involving both the library and clinical faculty. Dental hygiene faculty collaborated with a librarian to implement a project in which the dental hygiene students devised a patient scenario and then searched the Internet to find and then appraise information relevant to that scenario. This learning tool was perceived to be successful in teaching the students to evaluate evidence-based information.28 Koufogiannakis et al.,29 in a study of medical and dental students involved in problem-based learning, determined that librarians could play an effective role in the curriculum by teaching medical information searching skills for evidence-based medicine.
As a step in achieving the goal of a dental school curriculum based on the principles of evidence-based inquiry1 at the University of Texas Health Science Center at Houston Dental Branch, we developed and implemented an information technology course for first-year dental students with the overall goal of meeting the critical thinking and information management competencies set forth by CODA. We chose to make this course interdisciplinary by including basic science and clinical faculty members, as well as a librarian, as instructors.
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Methods
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An updated information resources training (IRT) course was introduced into the curriculum in the fall of 2003 at the Dental Branch to replace the previous online modules required of first-year dental students. These online modules were designed to familiarize the students with the information technology available to them. In reevaluating these modules, it was determined that entering students already knew the basics of information technology, including web searching and email, and that the Dental Branch should provide the students with a course that enhanced their ability to apply these techniques to clinical dentistry. The decision was made to provide an interdisciplinary approach, and a team consisting of a basic scientist, a librarian, and two members of the clinical faculty met to redesign this course. A librarian played an active role in redesigning the course and developing inquiry-based searches. The application of searches using controlled search terms and limits to searches was particularly helpful to students. The goals were to ensure that all entering students had fundamental computer and Internet skills necessary to function within the dental school environment and to introduce all students to the library/learning resources center, evidence-based dentistry concepts, information databases and search strategies, critical appraisal of information, and dental informatics. In addition, we sought to make the course as interactive as possible.
Several changes were made in the course in response to students’ comments from the first iteration of the course in 2003. The two major changes were the removal of introductory material such as how to use email and the addition of a hands-on session for learning search engines and strategies. In each subsequent year, refinements were made to presentations to make them clearer and to respond to student comments. The course remains a requirement for all first-year dental students and is given in the first half of their first semester in dental school. The number of students in each year was fifty-two in 2003, fifty-seven in 2004, sixty-nine in 2005, and eighty-one in 2006, totaling 259. The increasing number reflects the increase in admissions into the first-year class.
As currently constituted, the course consists of five lecture hours, one hour of hands-on training in database searching, and one hour of class discussion centered on clinical search topics chosen by the students. The clinical search topics led to preparation of a written assignment in which students reported outcomes of an evidence-based search for information. The lecture topics were evidence-based dentistry (two hours), critical thinking and evaluation of resources (two hours), and dental informatics (one hour). In the final hour of the course, students discussed the topics of their individual written assignments first in small groups and then with the class as a whole. The course schedule is shown in Table 1
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The first two sessions, taught by a clinical faculty member, introduced the students to evidence-based dentistry, formulation of a clinical question, the levels of evidence that can be obtained, and how to apply this information to dental practice. Fluoridation of community water supplies was chosen as a topic and used throughout the course as an example, since it is a topic familiar to all entering dental students. As expected, the students quickly realized that there are various levels of often contradictory evidence for this topic.
These sessions were followed by a hands-on session demonstrating database searching taught by the librarian. This hands-on session was added in response to students’ comments after the first year of the course. In the first year, the librarian gave a demonstration to the whole class in a lecture hall on the use of the various databases. Although she was able to show the students "live" how to do the searches, many students suggested that the session be done hands-on so they could practice the skills as they were being demonstrated. In subsequent years, the class was divided into groups of approximately twenty students for the hands-on training in database searching taught by the librarian in a computer laboratory in the Houston Academy of Medicine-Texas Medical Center (HAM-TMC) library, the main library for the six schools in the University of Texas Health Science Center at Houston and other institutions in the Texas Medical Center.
Following the hands-on sessions, the students met for two sessions taught by a basic scientist. These sessions introduced the dental students to the concepts of critical appraisal; the process of producing a manuscript including the peer review process; the types of resources and publications, both print and online, available to dentists and a process for critically appraising these resources; and the potential for conflicts of interest in research or clinical trials. The guidelines for the written assignment were based on this analytical process.
The practice of dentistry in the digital era was the focus of the last presentation by a clinician also trained in informatics. This presentation sought to define dental informatics in a general sense, which turned out to be consistent with the recent definition found in the American Dental Education Association’s 2007 draft "Competencies for the New General Dentist,"30 which defined informatics as "applications associated with information and technology used in health care delivery; the data and knowledge needed for problem solving and decision making; and the administration and management of information and technology in support of patient care, education, and research."31 The electronic patient record, dentistry in the post-genomic era, and teledentistry served as specific examples presented to the students.
In the final hour of the course, the students shared the clinical questions they developed and the results of their searches conducted to answer this question. The students broke into small groups (four to eight students per group) to discuss the topics of their individual written assignments. The students then came together in one group and shared some of the topics with the class as a whole. A complete list of topics posed by the students was posted to Blackboard for all students to view.
Student assignments for the course were completion of two online questionnaires available through Blackboard, emailing the results of the search completed in the hands-on session in the library computer lab to the instructor, and a written assignment evaluating one of the resources uncovered in searching for answers to their clinical questions. The first online questionnaire, completed by the second week of class, assessed students’ familiarity with technology, and the second, completed at the end of the course, asked them to evaluate various aspects of the course. This second questionnaire consisted of thirteen questions evaluated with a five-point Likert scale and three open-ended questions asking the students what aspects of the course they liked best, aspects they liked least, and aspects that could be improved. Relevant questions are listed in the corresponding tables and figure in the Results section below. The complete questionnaires are available from the lead author on request. The students were evaluated on a Pass/Fail basis.
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Results
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An IRT course consisting of interactive lectures and hands-on searching experiences was developed and implemented for first-year dental students. In order to assess each incoming student’s level of computer and literature searching skills, the students completed a "Technology Assessment Survey." This survey (required for completion of the course) indicated that >90 percent of the students in all years were familiar or very familiar with word processing, email, accessing the Internet, searching for information on the world wide web, using computers for online instruction, and using computers to download files and software. Approximately 30 percent of the students in each year were familiar or very familiar with using computers to create web pages. A large majority of the students (>95 percent) used the Windows operating system. In the most current class (2006), 11 percent of the students had computers with the Mac operating system. Approximately 75 percent use web-based email, and >90 percent have high-speed Internet access outside of school via DSL or cable modem. These results justified the shift in emphasis of the IRT course to emphasize EBD, critical appraisal, and dental informatics.
In the first section of the course, EBD was defined, and its application in the context of developing and formulating clinical questions explained. Several examples, including many aspects of the fluoridation of community water supplies, were given. In an interactive manner, students were challenged to give further examples related to fluoridation as well as to suggest additional clinical questions of interest to them. One of the course assignments was to formulate a clinical question and search the literature for answers to that question. The topics of the students’ questions represented a diverse spectrum of dentistry. A summary of those topics is shown in Table 2. The students were given little guidance in choosing topics and encouraged to choose topics of interest to them. Consequently, the topics varied greatly from year to year, but several, including aspects of periodontal disease, tooth whitening, and tobacco, were chosen frequently. Students discussed their chosen topics in small groups in the last session of the course. This allowed the students to share their information as well as search strategies with each other. A limited number of students also presented their information to the entire class.
At the conclusion of the course, the students completed an online course evaluation that was required for completion of the course. For the questions related to course and faculty organization, 80 percent to 90 percent of the students agreed or strongly agreed that the course and faculty were well organized, that the course syllabus provided direction and guidance for the course, that the faculty made the course interesting, that assignments highlighted important aspects of the course, and that the course material will be useful in the practice of dentistry. These results were consistent for all four years.
Six of the questions in the evaluation related to the specific objectives of the course covered in the lectures or demonstrations (Figure 1). Overall, at least 75 percent of the students agreed or strongly agreed with the statements that the information presented was valuable and that they learned the processes taught in the course. There was at least a two-fold increase in the number of students that strongly agreed with the statements over the four-year period. In addition, there was a decrease in the number of students disagreeing or strongly disagreeing with the statements.
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Figure 1. Results of student survey of course objectives
Each panel indicates the response of students, by year, to the specific question listed above each graph. The questionnaire was administered online, and the student responses tabulated automatically by the Blackboard software. The legend to the right defines each response.
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Three open-ended questions were also included in the evaluation; these asked the students what aspects of the course they liked best, what aspects they liked least, and what aspects could be improved. Table 3 summarizes the major themes expressed by the students in all four years. A large number of the students cited learning to effectively search the various databases as the aspect of the course they liked best. Approximately 10 percent of each class cited the individual lecture topics as best liked. Not surprisingly, approximately 20 percent of each class cited the written assignment as the thing they liked least. A number of students felt that the course was too elementary for dental students and should not be required. The fact that this number declined from 30 percent in 2003 to 10 percent in 2006 reflects the changing nature of the course content as the instructors included advanced level information that was more relevant to dentistry.
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Discussion
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This study describes the development, implementation, and evaluation of a course for first-year dental students at the Dental Branch that emphasized critical appraisal and its application to evidence-based practice. The interdisciplinary approach exposed the students to various aspects of developing search strategies and appraising the information obtained to answer questions that arise in their basic science and preclinical courses and clinical experiences in dental school. In addition, application of these tools to their future dental practice was emphasized. Our intent was to teach the concepts of critical appraisal, evidence-based dentistry, and dental informatics, as well as the application of these concepts to dentistry, so that the principles will be second nature to the students as they leave dental school and enter dental practice.
The results of the evaluation questionnaire completed by the students indicate that the goals for the course established by the faculty are being met. The students perceived that the course was well organized and that the specific objectives for each class session were increasingly met in each subsequent year of the four-year data collection period. The students valued the course emphasis on effective searching for information and critical appraisal of the information obtained.
The results obtained in this study are generally in agreement with similar studies done in other settings. Numerous studies involving medical and dental students, residents, and physicians show that learners in each of these disciplines value the opportunity to acquire critical thinking and appraisal skills, and our results concurred.6,7,11,14,15,17,18,21,25,27 A strength of our course lies in its interdisciplinary nature, which greatly facilitated meeting its goals. Each instructor brings expertise to the class and allows demonstration of the practical use for the information and skills being addressed. The students perceived the value of the librarian as indicated in their responses to the open-ended questions (Table 3
). An additional advantage was the role modeling occurring because of the interactions between the librarian and the clinical and basic science faculty members.
Given the apparent success of our efforts to educate first-year dental students in searching, critical appraisal, and evidence-based dentistry, the biggest challenge is thus to ensure that this knowledge will be applied by the students in other courses and clinics throughout dental school and beyond. These goals are supported by studies stressing the importance of providing students with training and practice of evidence-based medicine before they actually start using it in patient care.17 In support of the idea of integrating critical appraisal into the overall curriculum, Forester et al.32 examined the effects of introducing medical students to critical appraisal of the biomedical literature as part of their first-year histology course. Three years later, when assessed during clinical experiences, the students agreed that the critical appraisal module demonstrated the value of histology to clinical medicine and also indicated that they highly valued the program. Further support for this approach comes from an analysis of research published between 1996 and 2002 indicating that dental students in a problem-based curriculum that emphasized evidence-based practices scored higher on the National Boards Part I exam than students in a traditional curriculum.33 The authors of this study concluded that the evidence-based interventions increased student knowledge of medical topics and enhanced their ability to search and appraise the medical literature—which is the goal of our current course.
Accomplishing these goals will require education of faculty members in all disciplines so that they are able and willing to include these approaches in their courses. In the future, it will be possible to survey students as they progress through the curriculum to determine the effectiveness of their training in critical appraisal and EBD in the clinic. In addition, adaptation of the curriculum to allow more time and emphasis on this type of learning will be required. Recently, the American Dental Education Association (ADEA)’s Commission on Change and Innovation in Dental Education took the lead in curriculum revision by developing a set of updated "Competencies for the New General Dentist" (approved by the ADEA House of Delegates in March 2008),34 which place much greater emphasis on critical thinking skills. In addition, a forum for the scholarship of teaching and learning has been implemented at the ADEA Annual Session. These steps at the national level should provide the framework for implementation of strategies to enhance students’ abilities in critical appraisal and evidence-based practice at the school level.
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Acknowledgments
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We wish to thank Ms. Leah Krevit, former librarian at the University of Texas Health Science Center at Houston Dental Branch, for encouraging development of this course and for initial development of the online questionnaires.
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Author Information
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Dr. Levine is Associate Professor, Department of Biochemistry and Molecular Biology, University of Texas Health Science Center at Houston Medical School; Dr. Bebermeyer is Professor, Department of Restorative Dentistry and Biomaterials, University of Texas Health Science Center at Houston Dental Branch; Dr. Chen is Assistant Professor, Department of Pediatric Dentistry, University of Texas Health Science Center at Houston Dental Branch; Ms. Davis was Assistant Director of Information Services, Houston Academy of Medicine-Texas Medical Center Library; and Ms. Harty was Assistant Library Director, University of Texas Health Science Center at Houston Dental Branch. Direct correspondence to Dr. Alan E. Levine, Department of Biochemistry and Molecular Biology, University of Texas Health Science Center at Houston Medical School, 6516 M.D. Anderson Blvd., Suite 4.109, Houston, TX 77030; 713-500-4497 phone; 713-500-4500 fax; Alan.E.Levine{at}uth.tmc.edu.
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Abstract
Methods
