It is 7:00 am on a Monday in October, and the eyes of Dr. Morey Gendler's dental students are focused intently on a case presentation by their classmates. The patient is a 50-year-old male with severe dental difficulties, whose situation elicits sympathy from everyone. The students are participants in an Integrated Case Seminar, a new but already influential course that brings together participants from all four years of dental school to study and present a patient case together. In this case, the patient has periodontal disease and tooth loss. To complicate matters, he has HIV and hepatitis C. An intensive interview has turned up one of the sources of his dental problems: a tendency to sip sugary beverages throughout the day.
A four-student team, led by fourth-year dental student Pawandeep Sekhon, had six weeks to prepare their presentation; they started in August, before the start of school. It was up to Ms. Sekhon to select the patient from her clinical work, identify the relevant research questions with the help of two faculty mentors, assign tasks to teammates, and put together the presentation under the guidance of Dr. Andrew Spielman and Dr. Morey Gendler, who served as basic science/clinical faculty mentors.
Developed in 2009 by Drs. Andrew Spielman and Mark Wolff, the Integrated Case Seminars accomplish several objectives. For fourth-year students, the seminars add leadership and communication components to their existing case-study experience. For third-year students, the process is an immersion in evidence-based dentistry, as they develop a research question directly related to patient care and then seek the best evidence in order to select a treatment plan that best applies to an actual patient case being studied. The students utilize their Skills in Assessing the Professional Literature (SAPL) to determine the quality of the literature being applied to this case. For the first- and second-year students, who have been exposed to few clinical settings at this time in their education, the seminar is an opportunity to apply textbook learning right away to real situations. The first- and second-year students are expected not only to attend but also to present at the seminar. In each seminar, utilizing his or her newly learned research skills, the first-year student presents on the basic physiologic condition, and the second-year student discusses pathologic changes associated with the condition. Every student in the seminars has the opportunity to be part of the research and presentation team.
According to Dr. Wolff, Associate Dean for Predoctoral Clinical Education and Professor and Chair of the Department of Cariology & Comprehensive Care, the College of Dentistry is moving case-based education to an earlier stage of education-as early as the first week of dental school-so students begin to see how even the simplest of dental issues requires a thought process that must be incorporated into treatment decisions. He and Dr. Spielman, Associate Dean for Academic Affairs and Professor of Basic Science and Craniofacial Biology, also saw the value of beginning literature analysis at an earlier point in dental school. The seminars also have an interdisciplinary component: All dental hygiene students are enrolled in seminars, and the College of Nursing has begun enrolling nurse practitioner students in the seminars as part of the collaboration between the two schools. Many medical and dental schools have introduced a case-based approach to dental education in which traditional lecture- and practicum-based experiences are replaced by cases-often led by non-experts in the relevant content area. The expectation is that, somehow, all those things learned through more structured approaches will eventually be picked up through the more peripatetic, hit-or-miss approach of the case study alone. This is not that. Rather, these cases are in addition to NYUCD's more structured curriculum, are integrated across all classes and disciplines, and are evidenced-based.
The Integrated Case Seminars are each led by a faculty group practice director and a basic science/clinical mentor, who each teach 100 students, divided into 4 subgroups. Students attend a seminar once per month. Because of the numbers of students and faculty involved, the classes are held daily at 7 am. Not everyone is happy about the schedule, Dr. Spielman acknowledges. But at least one student, third-year Roman Tyomkin, says that it's worth getting up early to come to the seminar because students go out of their way to identify interesting cases, and it's always fun to listen to other people's perspectives.
Managing a Difficult Case
Among the problems facing Ms. Sekhon's patient is a history of ranula-a swelling of a minor salivary gland in the anterior floor of his mouth, as well as myofascial pain related to a work accident. He has extensive restorative therapy and missing teeth that cause aesthetic and functional problems. One emphasis of the seminar is to explore the medical issues that might interfere with treatment, and before planning her patient's treatment, Ms. Sekhon has called for a medical consult. His platelet counts must be high enough to go ahead with the procedure, or else excessive bleeding can occur, and his absolute neutrophil count is taken to see whether antibiotic prophylaxis is necessary.
The third-year student in Ms. Sekhon's team, Kenny Cheung, has researched the effectiveness of amalgam versus composite restorations to see which restoration is warranted in patients with active caries.
The second-year student in Ms. Sekhon's team, Nathan Der, had the job of explaining differential diagnosis and treatment of ranula, and the first-year student, Hee Soo Kim, discussed the different types of minor salivary glands and their roles.
Ms. Sekhon has put together two different treatment plans for this patient-a realistic and an ideal one, recognizing that the patient's Medicaid coverage will not cover all of the care he should optimally receive. At minimum, he needs three root canals and upper and lower dentures. Ultimately, she says, health promotion is the most important part of the plan. Little things, like switching to diet drinks, can make a large difference for this patient.
Learning Basic Science Through a Clinical Lens
Traditionally, schools say, "Let's teach basic science and at the end of the lecture mention how important it is in the context of cases." But freshmen may have little frame of reference for the science because they don't have clinical knowledge. This seminar reverses that. It takes a clinical case and drills down into basic science concepts.
Dr. Ivy Peltz, who teaches an Integrated Case Seminar, says that even if certain topics are above the level of first- and second-year students, exposing them to these ideas can only help them grasp the basic-science concepts they're learning. "It's exciting for them to enter the clinical experience with more knowledge," she says.
For the fourth-year students, the Integrated Case Seminars offer a teaching experience that they would not otherwise have had-and teaching a subject tends to ensure that it will not be forgotten.
Finding the Evidence, Questioning Convention
Ultimately, the purpose of the Integrated Case Seminars is to enable students to practice evidence-based dentistry so they will be prepared for a lifetime of seeking their own answers. Even though the core techniques taught at the College of Dentistry have always been based on the evidence, in the past the school did not put the burden on students to find the evidence.
"We will never have time to teach our students everything they will need to know over the course of their careers. By becoming men and women of science, they will have that crucial ability to find the evidence when they need it," Dr. Peltz says.
The seminars teach students not only to find research studies that are relevant to their cases but to rank the value of these studies. In a recent seminar taught by Dr. Peltz, a patient case was presented by fourth-year student Ryan Allen. The patient, a 58-year-old woman, brought to the clinic her high-school yearbook photo displaying a radiant smile. But now, her gingiva have receded, attempts to repair them have not been successful, and she wants her former appearance back. The question of which treatment would be most effective fell to third-year student Roman Tyomkin.
Mr. Tyomkin looked for studies comparing various designs of porcelain enamel veneers to see how successful they had been. Two studies that he found showed that a simple design was most successful. Mr. Tyomkin and Mr. Allen discussed the research and agreed that, while the studies were relevant, both relied on prospective and extrapolated data. In the absence of a systematic review or meta-analysis-the highest form of literature, which culls numerous articles-Roman explained that you have to go with the best evidence you can find.
"I think everyone in the room, including our professor, learned from these studies," Roman says. Mr. Allen's patient was a jumping-off point for second-year student William Chang to discuss the anatomy of the tooth. It's the hardest surface in the body, he said, emphasizing the importance of proper brushing with a soft toothbrush.
Dr. Wolff reminds students that the point of finding the best evidence is not merely academic. Patients want and deserve the best and most current care. Drs. Wolff and Spielman are coauthors of the 2008 article "Evidence-based Dentistry: Why It Should Become Standard Practice" in the Journal of Dental Education. They are on a mission to ensure that as dentists, their students will base their treatment decisions on evidence and not on what they have seen practiced or even necessarily what was taught to them.
"We want them to question convention," Dr. Wolff says, "to ask, ‘Why are we doing this?' This can be a tough question for students and faculty alike."