Combining Technology and Ingenuity to Educate Tomorrow's Dentists
Problem-based Learning and the Simulated Patient


Since 2001, NYU dental students have had the opportunity to learn foundation skills, gain clinical ability, and practice decision making in a spectacular clinical simulation facility before they have actual patient contact. This learning methodology is based on the premise that the efficient and effective practice of dentistry demands that students have constant and ready access to emerging knowledge and possess the highest level of technological proficiency. But our faculty also recognize that being competent to mechanically perform even the most complex procedures is not the same as being a great clinician, one who is concerned about the patient’s overall well-being. Given the role of technology in modern dental education, the question becomes: "How, in a room filled with simulators, is it possible to develop clinicians who are capable not merely of technical competence, but of gathering and utilizing the best information available to be applied to patient care?"

To meet this challenge, NYUCD has adopted an innovative teaching strategy throughout our second-year preclinical restorative dentistry course based on problem-based learning (PBL) that, in essence, views the simulation environment as a real-life private practice setting and the simulated patients as members of an actual family, with a unique constellation of physical, psychological, sociological, economic, and behavioral traits.

PBL was pioneered more than 30 years ago by medical school faculty at McMaster University in Canada, in response to the frustration expressed by medical students--and faculty--who felt that traditional methods of lecture presentation left them unprepared to deal with challenging clinical experiences. To remedy the situation, McMaster University made the decision to move from a faculty-centered approach to a student-centered, interdisciplinary process using actual clinical cases, which puts students in the driver's seat in dealing with challenging clinical situations and recasts faculty as "facilitators," rather than traditional authority figures. PBL is now widely used at medical schools in the U.S. and Canada, including the Harvard Medical School. But PBL is not limited to medical and dental education; it is also used in business and legal education and other areas where educators have recognized the limitations of the lecture methodology and have begun to seek alternative methods of instruction.

Problem-based learning requires the student to look deep into the clinical situation. Does the patient have a "high" risk for caries? What is the patient's oral home care regimen? Is the patient exposed to daily fluoride levels? Is diet a critical factor? Is the patient's blood pressure significantly elevated? Is the patient diabetic? Has the patient had a recent myocardial infarction and balloon angioplasty? Is the female patient pregnant? How do these facts impact the use of local anesthetic, the length of a treatment visit, or the need for a medical consultation?

In managing the simulated patient, students learn how to interpret the information presented and where to find the relevant treatment guidelines for the information. They learn to integrate all of the information into appropriate care decisions, in contrast to viewing the facts as isolated phenomena, which are more difficult to integrate than facts taught in a realistic context. The result is a reduction in the potential for acquiring "inert" knowledge-learned information that is difficult or impossible to apply to realistic situations.

Each week, a new "patient" from this "family" presents for treatment. Prior to beginning treatment, students receive written information, radiographs, and case background material for the simulated patient-problem scenario. The students are required to complete a treatment plan prior to arriving in class, and are encouraged to work collaboratively and to focus on identifying clinical issues applicable to the resolution of the problems of their particular "patient" for the day. They must decide which teeth may require care, how health and social issues may modify the treatment to be delivered, and what the patient's risk factors are for disease. For example, the patient may not want "mercury" fillings; the patient may have just lost his job and his dental insurance; the patient may have received a conflicting diagnosis from another dentist. Students must recommend tobacco cessation for patients with histories of smoking, and they must make recommendations for the presentation of all diseases, NOT just the decay to be treated that day. Students quickly learn that we treat people, not teeth.

It is important in PBL to take an incremental approach in order to avoid overwhelming the student with the complexity of clinical situations. We begin with simplified versions of real clinical situations and progressively add components. This enables students to engage with one another in meaningful problem solving. In the process, students develop independent reasoning skills that can be evaluated and strengthened by the faculty facilitators.

Student comments are the barometer by which we judge the program’s success. Seth Rubenstein, Class of 2011, has this to say: "At NYU, our operative lab work has been designed to help correlate preclinical treatment with patient care and ultimately help us transition into the clinic more smoothly. This approach teaches us to treat patients comprehensively. We enjoy the challenge of using information gained from all parts of our education--pharmacology, dental anatomy, radiology, cariology, etc.—and applying it to patient care scenarios. This more realistic, preclinical approach allows us to see the big picture of the work we are doing in the labs rather than blindly completing an assignment on a typodont. Instead, our assignments are intertwined with real scenarios, such as a patient concerned with the esthetics of their smile, or one with limited finances."

Adds E. Matthew Lamb, Class of 2011: "This training has emphasized that a good restorative preparation does not, in its own right, makes a great dentist. Patients will never see our expertly done preparations or artistically carved occlusal anatomy. Instead, they’re concerned about our ability to diagnose the problem correctly and to treat it in a way that is proper--perhaps even preventing it in the first place! This medical approach to dentistry is what builds a trusting relationship with patients and what ultimately defines a good dentist."

Our students' enthusiastic reaction to diagnosing and treating a "patient," rather than just performing a mechanical procedure on a plastic tooth, is the best outcome we could hope for. This process has strengthened their ability to transition into the clinic setting and has brought a new sense of accomplishment to both students and faculty.