Dr. Paul Goldhaber, the former Dean at Harvard, is said to have remarked, "Dentists are the most overeducated people for what they do and the most undereducated people for what they might do." In recent years, a number of dental schools have begun to address this imbalance, which is essentially a disconnect between the knowledge of basic science that dentists acquire in dental school and the clinical science that they practice. But how far have we actually come in our ability not only to produce clinicians, but also to educate dentists who demonstrate the added value that is the difference between a professional education and a technical education?
That question was on my mind in May 2003, during a faculty and staff retreat convened by the School of Dental Medicine at Case Western Reserve University to consider the skills, knowledge and values that will define the superior dentist in 2020. The retreat was intended as a first step in designing a new curriculum to provide Case students with the education required to become superior dentists of the future. As I listened to the discussions, I found myself wondering what that future might be. Would it be a refinement of the past, a continuation of the status quo, or could it be something bolder? And it occurred to me that perhaps before we rethink the curriculum, we should rethink the future of dentistry. This essay is intended to share my thoughts on the subject, rather than to offer a prescription to others.
How well do we in dental education promote a culture of inquiry and continuing evaluation that consistently links basic biological and clinical sciences in order to produce not solely the next generation of practitioners, but also the next generation of educators and researchers? Are today’s practicing dentists critically evaluating their patients’ general health; frequently writing prescriptions; routinely updating their understanding of the new drugs their patients may be taking; and are they engaging in risk assessment and applying this information to patient care?
Dentists and all healthcare professionals must have a deep understanding of how the body works, how disease processes occur, and how interventions (both pharmacologic and surgical) work. But dentists tend not to think of themselves as treating disease, which puts dentistry at a disadvantage when it comes to public funding, because policymakers only fund those who treat disease. It is perhaps even more important that we dentists know how to monitor patients and help populations of patients to maintain their health. To do this, we must be able to find information, evaluate it, and apply it to patient care. How else can we continually evaluate new drugs and procedures and bring new understanding to issues related to health and disease? In this regard, are we doing enough to help our students understand newer technology, to learn to think critically, and to conceptualize, rather than to memorize. In short, are we doing enough to enable them to become lifelong learners?
Are we teaching students that an interdisciplinary approach is no longer optional? That whether we’re generalists or specialists, we are integral members of the larger medical and surgical healthcare team, professionals who share a similar background and vocabulary and bring interdisciplinary knowledge and skills to the challenge of improving the well being of individuals and populations?
I would hope that all dentists would recognize untreated COPD (chronic obstructive pulmonary disease) in a patient and would follow up to ensure that the condition is being addressed. Similarly, a prosthodontist might play a role in smoking cessation; a general dentist could assist his or her diabetic patients in relation to weight loss; and, on the flip side, physicians in rural areas could benefit their patients by applying fluoride varnishes. Perhaps it is time for a team consisting of a dentist, advanced technician, hygienist, and nurse practitioner or physician’s assistant all working together to provide a different array of care.
Ultimately, these thoughts helped to shape not one, but two curricula at Case. One curriculum focuses on restructuring the predoctoral program (our primary program) to ensure not only technical excellence — which remains the foundation on which all else is built — but also to foster a culture of inquiry. To this end, we are using a new pedagogy called the REAL curriculum, a set of core principles which promote communication skills, independent learning, leadership, the use of technology, lifelong learning, and careful evaluation of science and practice to nurture practitioners who are appropriately educated not only for what they do, but for what they might do. At Case we believe that what they might do is to evolve into a different kind of primary healthcare provider, one with a broader scope than currently exists.
The other curriculum supports a fiveyear, combined degree program (for between two and six students) that offers both a dental and a medical degree. The combined DMD/MD program shares all of the goals and methods of the REAL curriculum and, in addition, aims to create a new class of healthcare professionals who, by virtue of their dual training, transcend traditional categories, allowing them to think more expansively about the care they provide, especially in the areas of behavior modification and compliance with treatment for chronic conditions, two of the most important challenges in health care today.
REAL is an acronym for Relevant, Experiential, Active Learning. Because we at Case believe that dental education should be Relevant, we have deleted unnecessary information and replaced it with new information and emerging technologies. Dental education should also be Experiential, a focus derived from our extensive, healthpromoting, firstyear experience in which students travel to almost 100 elementary schools to provide care—including the placement of sealants—three months after entering dental school. Students tell us that their ability to learn concepts such as infection control, materials, child management, etc., is sharpened by the fact that they will so quickly be challenged to provide care. The REAL curriculum builds on this approach by including four similar experiences during the first two years so that students are continually challenged to prepare for something that is "just around the corner."
The REAL curriculum also emphasizes smallgroup, Active Learning methods (problembased, casebased, and team learning.) In addition, subject material has been reorganized according to themes that cut across traditional disciplines; namely, health and well being, maintenance of health disease processes and restoration of health. The curriculum also emphasizes comprehensive care in a multidoctor office setting, the ability to apply management principles and vertical integration of clinical experiences over four years.
It is very difficult to paint a picture of the future, but I am convinced that these concepts point the way to dentistry’s potential and, indeed, obligation, to demonstrate increased professionalism and value to the public. A basic tenet of leadership is that you spend time doing the things that only you can do and delegate the rest to others. In this way of thinking, dentists learn to share responsibility and to delegate so that they can involve themselves more with evaluation, diagnosis, treatment planning, office management, continuous learning, and communicating with patients and other healthcare providers.
Another core principle that emerged from our deliberations is the value and importance of students in different healthcare professional training programs working together to solve patient problems. This principle is reflected in Case’s new DMD/MD program, which will begin in fall 2008.
The DMD/MD curriculum is fully integrated between the dental school and the medical school so that the educational objectives of both programs are met and merged, rather than being presented as discrete entities, one followed by the other. The students in the DMD/MD program are required to achieve all the outcomes of the REAL curriculum, but they are also expected to develop an expanded ability to diagnose, treat, and prevent a much broader array of health problems. For many years, the Institute of Medicine (IOM) has called for health professional schools to stop educating students in ’silos’ when patients expect them to work in collaborative teams in clinical practice. We feel that the DMD/MD program is a step in that direction. Importantly, it allows students to work together in the clinic, as well as the classroom. Equally important, it places Case in an excellent position to continue to research the many evolving links between oral health and general health. Another benefit is that students in the DMD/MD program are exposed to an additional group of professional role models. It is our hope that from this nontraditional education and experience will come a new kind of healthcare provider, one who synthesizes the best of both dentistry and medicine.
Both the REAL and the DMD/MD programs are part of a wave of change occurring in dental education. I believe it is important that many approaches be tried so that we can learn from and adopt the best practices. But it is also important to recognize that dental schools alone can’t determine the future of the profession. Students derive their values, knowledge and goals from what they see the American Dental Association (ADA) do, from their colleagues and associates, from the practicing community, and from what they see in magazines and movies, as much as from what they learn in the classroom and clinic. That’s why I say that rethinking the future of the profession is as important as rethinking the curriculum. That’s the journey we must all make, whether it be dental schools, the ADA, the licensing community or individual dentists.
On a personal note, I want to thank Dr. Richard Vogel and the staff of Global Health Nexus for the opportunity to share my views on the challenges and opportunities dental education faces in preparing students to become 21st century healthcare providers. I think that in making the decision to invite outside opinions, the NYU College of Dentistry has introduced a welcome innovation in dental school publications.