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Abstract
Lawsuits in dentistry are increasing, and often a legal dental expert witness is called to provide an expert opinion. The appointment of the expert witness is rather arbitrary since special requirements for expert witnesses do not exist. Qualified written expert opinions, however, are particularly relevant for the dental profession. The Karlsruhe Training for Legal Dental Expert Witnesses (KT) was introduced as the German approach to this problem. The KT is a training program based on the principles of continuing professional development (CPD) that trains dentists to give written expert opinions and to act as expert witnesses in all types of legal matters. The aim of the study was to assess the quality of the KT according to the requirements of CPD. A written survey was conducted among the 161 participants in the KT between 2004 and 2009. It contained questions to assess the quality of the program and to evaluate its impact on the professional performance of the participants. The return rate was 51.6 percent (n=83). The analysis shows that the KT achieved its main goal to train the dentist as a legal dental expert witness and that the KT does not only transfer formal knowledge but stimulates changes in personal development as described in the concept of CPD.
- dentists
- continuing dental education
- lawsuits
- malpractice
- lifelong learning
- forensic dentistry
- expert opinion
- expert witness
- Germany
The number of lawsuits in the health professions in industrialized countries is increasing. In dentistry, implant treatment, oral surgery, and prosthetic rehabilitation are leading fields for malpractice claims.1,2 For many claims, a legal dental expert witness is called to provide an expert opinion. The expert witness usually is appointed by the court rather arbitrarily since, in most countries, there are no special requirements or qualifications for acting as an expert witness in court. The reaction of the dental profession in Germany was to implement the Karlsruhe Training for Legal Dental Expert Witnesses (KT), a continuing education program based on the principles of continuing professional development (CPD).1 Qualified written dental expert opinions are particularly relevant since the general assessment of the value of dental performance affects the autonomy of the dental profession.1 This becomes obvious if the clarification of an implantological, surgical, or prosthetic issue is not presented to the court conclusively in form and content.
The concept of CPD means that the KT is characterized by lifelong learning in which science, further education, and practical experiences add up.3–8 Further education in general is considered an essential instrument of quality assurance in health care.8,9 Ideally, further education provides not only for quality assurance and quality control, but improves the quality of care provided by individual professionals. The concept of CPD and recent approaches for its evaluation measure the quality of seminars not only by the number of participants, their satisfaction, and their cognitive increase in knowledge, but also by their influence on delivered care to the patient and contribution to practice performance.4,5,10,11 Common criteria for effective health professions training are interactive learning in groups, learning according to the demands and according to personal experience, individual mentoring by experts, transfer of the ability to make decisions, and the motivation for further studying.6,12,13
The aim of this report is to introduce the KT as an instrument for professional development in dentistry and to investigate the quality of this training program focusing on the requirements of CPD. Therefore, we conducted a written survey among the participants from 2004 to 2009 in collaboration with the University of Applied Sciences Northwestern Switzerland, Institute for Higher Education in Applied Psychology.
Materials and Methods
In 1996, the Karlsruhe Institute of Continuing Professional Development initiated an advanced training program for legal dental experts in Germany. The KT has the intention to train dentists as legal dental expert witnesses and to improve the quality of written dental expert opinions.1 It is based on the concept for CPD and consists of five weekend seminars (Table 1). Case reports and their workups are presented by experienced legal dental expert witnesses, and recent cases are discussed in small groups under supervision. Between seminars, the participants communicate in online meetings and can use a variety of tools in the virtual lecture hall. During the last seminar, the participants present their own case workups in the plenum.1
Organization of the Karlsruhe Training for Legal Dental Expert Witnesses (KT) program
All 161 participants in the KT for 2004–09 received a written partly standardized questionnaire containing questions about the KT. The questionnaire was designed under the supervision of social scientists and was pretested by five dentists to assess its practicability and comprehensibility. It contained open and closed questions on these topics: motivation, didactic methods of the course, effect of the course, and implementation of the gained knowledge. There were also blank spaces for further comments. The questionnaire was mailed together with a self-addressed prepaid return envelope. We performed quantitative, qualitative, and descriptive analyses of the collected data.
Results
Eighty-three analyzable questionnaires were returned within a ten-week period (return rate 51.6 percent). The responding participants were equally distributed among the years of participation. Twelve (14.5 percent) of the participants were under forty years of age, thirty-four (40.9 percent) between forty and fifty years, twenty-five (30.1 percent) between fifty-one and sixty years, and twelve (14.5 percent) over sixty years.
The motivations of the participants who completed the training were discerned from the free text passages. These comments revealed an instrumental motivation (“to act as legal dental expert witness,” “expand knowledge”), a general motivation (“see things from a different perspective,” “exchange/discussions with colleagues,” “enjoying advanced training”), and a preventive motivation (“avoid mistakes of others/self-protection,” “previous experience as defendant”). In the directed question on the participants’ main expectations for the training, the “acquisition of competence as a legal dental expert witness” was the most frequently chosen answer (n=70). This expectation was satisfied in 94.3 percent of the cases (n=66).
As far as the methodological instruments were concerned, the speakers’ lectures were evaluated as helpful by all the participants, and the moderated discussions in small groups were said to be beneficial by seventy-three participants (90.1 percent). In this part of the questionnaire, participants were also able to make their own comments. The group work was said to be “very cooperative“ and “very honest,” but discussions were said to be too long because of differing opinions between participants who had been called as expert witnesses and participants without previous experience. The presentation of the results of the discussion groups and the presentation of their own cases in the final seminar were rated as useful by most of the participants (91.0 percent). The virtual lecture hall was rated less highly, though still with a positive rating of 73.1 percent (Table 2).
Study participants’ evaluation of the KT methodological instruments
Participants were also asked, “How did the course influence you?” (Table 3). The KT was said to have particular consequences for “knowledge about written dental expert opinions.” For dentists who had already testified as legal dental expert witnesses, the course was said to impact their management of written legal dental expert opinions. The course was also reported to have influenced participants’ attitude towards the dental profession, had an effect on their own work as dental practitioners, and changed their self-assessment of practical performance. One-third of the participants even reported a change in the delivery of care to their own patients. For about half of the group, the participants’ attitudes towards other dental practitioners and their professional performance also changed immensely.
Study participants’ perceptions of the impact in specified areas of participating in the KT
Forty participants (48.2 percent) said they had been called to testify as legal dental expert witnesses before they started the training. After the training, thirty of the forty-three participants reported starting to deliver legal dental expert opinions.
Thirty-eight participants (45.8 percent) made suggestions for the improvement of the KT. Four (4.8 percent) recommended discussion/presentation of more cases. In some of the comments, the participants said that their favorite field of specialty was underrepresented—for example, cone beam computed tomography, orthodontics, diagnosis and therapy of temporomandibular disorders, and disputes about fees. Furthermore, the topics of invoicing for written legal dental expert opinions and oral presentations in court were fields of interest that were suggested to be added in the next seminars.
Discussion
The return rate of 51.6 percent can be interpreted as sufficient. Other studies on continuing education for medical doctors and dentists show similar rates.3,14 According to our data, we cannot support the conclusion drawn in another study that younger dentists (under forty-five years) in Germany attend seminars more often than older dentists.15
The study found the participants had various reasons for attending the KT. Some had an instrumental motivation: simply to become a legal dental expert. If the participant had already been working as a legal dental expert, the motivation was to acquire the basic skills in retrospect. Some motivations were more extrinsic (e.g., economic success, improvement of the business image), and others were intrinsic (quality of treatment, job-related satisfaction, being a “good dentist”).15 The intrinsic motives are highly related to the professional identity of the dentist.15 Another important motivation we found for participating in the KT is to be protected against legal disputes with patients. It needs to be discussed to what extent the KT can address this self-protective motivation and whether it wants to try to meet that objective. There is no doubt that the self-protective motivation is the wrong primary one for participating in this training, but it might develop as a secondary effect. The responses support that the primary aim of the KT to train dentists as legal dental expert witnesses is being accomplished.
The participants were positive about the speakers and moderators, and the majority reported that the moderated, supervised group work was beneficial. The participants without previous experience as legal dental expert witnesses seem to have benefitted the most from the group work. In medical education, the personal exchange of knowledge in small groups is preferred to more anonymous conventional lectures in big lecture halls.13 Our participants rated the presentation of group work in the plenum as less beneficial. These presentations are obligatory for exchanging the results of the small group discussions and are obligatory to reach a consensus. The presentation of participants’ own cases and workups in the final seminar seem to be viewed as useful for the learning process in clinical reasoning and decision making. The rating of the virtual lecture hall varied among the participants, and perceptions of its value were not correlated to the age of the participants. At this point it remains uncertain if the advantages of the virtual lecture hall, such as higher flexibility concerning the extent of the studies and the choice of topics as well as the time for studies, will allow it to replace the traditional form of face-to-face learning.6,16
As expected, the participants reported that their knowledge about dental expert opinions had increased as a result of the course. Some of the participants said they had benefitted to a great extent, though even those who reported benefitting to a less extent felt reconfirmed in their present work. One-third of the participants said the KT had direct consequences for their interactions with their own patients. Half of the participants reported that their attitudes towards other dentists and their performance had changed to a great extent. The majority said that their self-assessment of their professional performance had changed immensely. One can speculate that the participants become more secure in evaluating their own work and can explain their own activities with more confidence. On the other hand, it is possible that the participants become more aware of their deficits and will change them in the future. The disadvantages of the questionnaire became apparent when we evaluated the question on the effects of the KT on the participants since the intensity of the consequences was requested (Table 2), but the direction of the effect was not.
The case discussions in the small groups were controversial among the participants. The individual assessment and emphasis on certain parameters of the cases (e.g., interpretation of diagnostic findings, degree of informed consent, choice of treatment, and differentiation between complication and malpractice) were said to lead to a change in their attitudes towards their colleagues and initiated personal and professional self-reflection. This can be interpreted as a sign that the KT achieved its goal in the sense of CPD to have a broader spectrum that also has an impact on the personality of the participants. This effect on the personality is possible because the dentists had a concrete motive for participating in the course and because the KT involves topics/cases on the borderline of daily dental practice. The course helped the participants gain knowledge about written legal dental expert opinions in a narrower sense, but also was perceived to improve their competence as practitioners. The training has a supplemental educational effect because cases are presented and judged from different perspectives, and the reflexive abilities for judgments are developed.1 After the KT, one-third of the participants who did not have previous experience as legal dental experts started to gain such experience. The 2009 training had just ended when the questionnaires were sent out. This might be too early to evaluate whether they have started to work as legal dental experts.
The comments showed that written expert opinions were perceived to be time-consuming, which discourages the dentists from preparing them. Additionally, only very few were shown to be proactive about approaching dental institutions or the courts. Some legal dental experts have extended their knowledge and enlarged their activities as legal dental expert witnesses.
The educational sciences have developed concepts for the evaluation of further education. When these ideas are transferred to advanced education in health professions, we can state that a good questionnaire must serve its purpose, which means in our study that the investigators receive useful feedback and information on the planned implementation (quality assurance and quality improvement of the KT).12 Next to the criteria of practicability, the reliability and construct validity are the most important and most frequently determined criteria.12,17 Reliability and validity were not assessed in this study. To determine the validity, we would need external criteria—for instance, the participants’ actual activities as legal dental expert witnesses before and after the training. For determination of the reliability, comparative measurements and repeated measurements would be obligatory. Both instruments of quality measurement were too complex to include in this preliminary study.
For the scaling of the answers to certain items, a rating scale with an even or uneven number of answer possibilities has been proven and tested mainly because it is easy to apply (Tables 2 and 3) and can easily be transferred into percentage values.17 Also, it is important that the participants get the chance to make own comments. These individual statements give direct responses to the organizers. As a result of one of the individual comments, some outdated materials in one seminar have already been replaced, and as far as possible we are planning to react to all other suggestions. Considering the high level of responsiveness to the survey among these participants, this instrument may be considered ecologically valid to a limited extent (i.e., it represents the object appropriately).18
Conclusions
Our study suggests that the KT is achieving its aim of training dentists to become legal dental expert witnesses. The didactic instruments, especially the lectures from the experts, the moderated learning in small groups, and the presentation of the participants’ own cases, were perceived as being very helpful by the majority of the participants. The indicators show that the KT is achieving more than simply training the dentist to be a legal dental expert witness, as it has an even broader spectrum of training in the sense of CPD. For the dental profession, it is not only important for graduates to satisfy the core competences of patient care such as diagnosis, treatment planning, and treatment, but also to develop their reflective abilities. For these reasons, training legal dental expert witnesses has a role in the development of the profession.
Acknowledgment
The authors thank Dr. Gwendolin Marie Manegold for her critical review and support with the English version of the manuscript.
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