Future Directions in Dental School Curriculum, Teaching

75th Anniversary Summit Conference 1

Future Directions in Dental SchoolCurriculum, Teaching, and LearningWilliam D. Hendricson, M.S.; Peter A. Cohen, Ph.D.

Mr. Hendricson is an Educational Specialist, Division of Educational Research and Development, The University of TexasHealth Science Center at San Antonio; Dr. Cohen was formerly Associate Dean for Academic Planning and Development,The Texas A & M University System, Baylor College of Dentistry, and is now Dean, School of Allied Health, Wichita StateUniversity. Direct correspondence to Mr. Hendricson at Division of Educational Research and Development, The Univer-sity of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284-7896;[email protected] e-mail.

Abstract: Efforts to reform the predoctoral curriculum are examined in light of the public’s past and future oral healthneeds. Three directions that may make a difference in the preparation of dentists for their professional roles are discussed:competency-based curriculum, blending dental education into the broader system of health professions education, andreform of clinical education. A blueprint for a new and different twenty-first century predoctoral curriculum is unveiled tostimulate discussion and debate within the dental education community. The last section explores the sociology of institu-tional change, identifies barriers to innovation, and offers recommendations for enhancing future curriculum reform efforts.

Key words: dental education, curriculum, dental students, oral health, institutional change

In 1972, a World Health Organization commissionassessed health professions education in many re-gions of the world including the United States. The

commission concluded that education is inextricablyinterwoven with the health service system, and whenquestions arise about the delivery of service, questionsabout the training of health care providers follow soonafter.1 And indeed, in the twenty-six years since thatprophetic report, a torrent of questions has been un-leashed in the United States about the way medical careis provided for the public, leading to a still evolvingreconfiguration of the health care landscape and, aspredicted, scrutiny of the way health care providers,including dentists, are prepared for their professionalroles in society. Managed care has become the founda-tion of the health care system, but much of the publicdoes not like it, and health professionals have concernsthat a “culture of commercialism” now dictates pro-fessional mores and manipulates decision making forpatients, leading to a loss of autonomy and personaldiscretion in care of patients.2 More than 900 bills wereintroduced during 1996 and 1997 in state legislaturesand Congress to curb the excesses of managed care.3

Even within the managed care industry, there have beenproposals for a “patient-centered” profile rather than a“profit-centered” model, and the new CEO of Colum-bia/HCA has publicly addressed “cultural” problemswithin the industry that promote overly aggressive man-

agement.4 Until 1996, the health care marketplace wasmoving steadily toward capitation and the capture ofemployee pools by managed care plans that offeredenrolled patients limited provider choice or serviceoptions. Just three years later, consumer choice has re-emerged as a priority, with corresponding focus onimproved access and flexibility, convenience, qualityof services, and consumer satisfaction. How far the anti-managed care pendulum will swing is unclear, but thenext ten to twenty years are likely be marked by con-tinued turmoil in the health care marketplace and, byassociation, within the institutions that train health careprofessionals.

The purpose of this paper is to highlight new di-rections for the dental school curriculum and for teach-ing and learning within the curriculum. To accomplishthis task, we’ll start by examining where dentistry, as ahealth care profession, has been and where it appearsto be heading based on the projected oral health needsof the public in the twenty-first century. In the secondsection, we’ll assess the extent to which dental educa-tion responded to the changes in the public’s oral healthneeds over the past fifty years and to calls for reformof curricular structure and teaching techniques. In thethird section, we’ll examine three new directions webelieve can make a difference in the way dentists areprepared for their professional responsibilities: 1) de-velopment of a competency-based curriculum, 2) blend-

2 American Association of Dental Schools

ing the education of dental professionals into thebroader system of health professions education by fo-cusing on areas requiring multidisciplinary patient care,and 3) reform of the environment in which clinical edu-cation occurs. As we examine these three issues, wewill describe a preliminary blueprint for a “new look”predoctoral curriculum for the twenty-first centurywhich we hope will stimulate reflection and discussionabout predoctoral dental education in the future. In sec-tion four, we’ll explore the sociology of institutionalchange, identify barriers to innovation, and offer rec-ommendations for enhancing efforts to reform the cur-riculum. Some of the recommendations in section fourare based on assessment of major curriculum innova-tion initiatives at eight U.S. medical schools supportedby implementation grants up to $2.5 million each fromthe Robert Wood Johnson (RWJ) Foundation. RWJ pro-vided substantial support for evaluation of both reformprocess and curricular product at these schools whichcontributed to a valuable summary of curriculum de-velopment strategies of pertinence to dental schools an-ticipating a similar journey.

Oral Health Care in the UnitedStates and Its Impact on DentalEducation

In his post-World War II speeches, WinstonChurchill used the words “the winds of change areblowing and we lean into them with equal measures ofanticipation and dread” to capture the conflicting emo-tions that arise when established institutions and meth-ods are questioned.5 The winds of change have beenblowing since the 1980s in U.S. health professions edu-cation, first as a gentle breeze but now as a more for-midable gale that is more difficult to ignore. The 1984report of the Association of American Medical Col-leges (AAMC) panel on the general professional edu-cation of the physician (known as the GPEP report)and the reports of the Pew Health Professions Com-mission were catalysts for curricular introspection inmedical schools and other health professions.6-8 Thedental education community embarked on an analysisof its own curricular health approximately ten yearsago. This introspection led to the 1995 Institute of Medi-cine (IOM) study which proposed reform of curricu-lum content and modernization of teaching/learningmethods.9 Significant changes in accreditation guide-lines also occurred in the 1990s including adoption of

an outcomes assessment approach to measure institu-tional effectiveness and adoption of a competency-based assessment philosophy which is being institu-tionalized by virtue of the new standard two(educational program) guidelines of the Commissionon Dental Accreditation.

In the years immediately following World WarII, dental caries and periodontal disease were assumedto be nearly universal, with a high percentage of pa-tients experiencing rampant caries, severe periapicalabscesses, and advanced periodontitis. The dental com-munity reached this conclusion without benefit ofmodern epidemiological techniques, but the estimatewas probably not too far off the mark in the pre-fluo-ride era. Since tooth extraction and physical removalof caries were the primary treatments available, restor-ative and prosthetic methods dominated the predoctoralcurriculum. Several decades of research into the bio-logical etiology and mechanisms of dental infection,leading to enhanced prevention and therapeutic regi-mens, and the widespread use of fluorides as a prophy-lactic mechanism have substantially reduced tooth lossand incidence of caries in child, adult, and geriatric agegroups.10 Further progress in prevention and therapy isanticipated as research expands our knowledge of themicrobial and genetic underpinning of oral diseases,and our understanding of the relationship between oralhealth and a variety of systemic disorders such as dia-betes mellitus, neutrophil disorders, stress, osteopenia,cardiovascular disease, and perinatal abnormalities. Aswe enter the twenty-first century, oral health is betterthan ever for the majority of Americans, but new chal-lenges have emerged. One in four children in the UnitedStates live in conditions of poverty normally associ-ated with an impoverished developing nation rather thanan industrial power. The health status of these childrenparallels their economic circumstance and, among thisgroup, indices of oral health are poor. A National Insti-tute of Dental Research study revealed that 80 percentof all childhood dental problems occurs in 25 percentof children, primarily those of low income and minor-ity status.11 One-third of all Head Start preschoolersand 50 percent of Native American children have earlychildhood caries (ECC) which has been clinically cor-related with compromised oral function, poor nutrition,and diminished height and weight attainment. Althoughinfant mortality rates have decreased over the pasttwenty years, the overall incidence of low birth weightpreterm infants has not declined despite substantialemphasis on prenatal care and preventive interventions,resulting in a significant level of perinatal morbidity,


untold emotional distress among family members, andexpenditures in the billions of dollars. Research atten-tion is now focusing on other previously unrecognizedrisk factors, including periodontal infection. For ex-ample, recent investigations suggest that pregnantwomen with severe periodontal disease are at consid-erably higher risk to deliver preterm low birth weightnewborns.13 Infectious oral disease has been identifiedas a potential etiology for up to 20 percent of the one-quarter million premature low birth weight infants bornin the United States annually, perhaps as a sequalae oftoxins from oral pathogens that reach the placenta anddisrupt fetal growth and development. Oral health isalso intertwined with childhood diseases includingasthma and cystic fibrosis. Asthmatic children havemore decay affecting permanent teeth, poorer periodon-tal status, and more loss of tooth surface than their non-asthmatic peers.14 The higher incidence of caries in chil-dren with restricted airway disease is thought to beassociated with their use of beta 2 agonists which con-tribute to reduced salivary flow, as well asmouthbreathing and esophageal reflux which is com-mon in this population.15 The poor oral health in chil-dren with chronic respiratory and gastrointestinal in-fections has also been associated with long-term useof liquid medications containing carbohydrates andsugar.16 More than 150,000 infants are born with birthdefects each year in this nation, and defects affectingthe orofacial complex are the most common, resultingin more than one billion dollars of expenditures annu-ally for their repair and rehabilitation.17

At the other end of the age continuum, the seniorcitizen (sixty-five years and older) represents the fast-est growing segment of our population. In 1900, themedian age in the U.S. was twenty-three years and only4 percent of Americans were sixty-five years of age orolder. By 1990, 13 percent of the population was agesixty-five and by 2050, more than 20 percent of thepopulation will be sixty-five years or older.18 Further,by the year 2020, it is projected that 60 percent of hos-pital admissions and one-third of all medical outpa-tient practice will be geriatric patients. Estimates of ge-riatric patients in dental practices are in a similar range,from 20 to 30 percent, suggesting that in the future asubstantial portion of dental patients will present withan array of overlapping medical and oral health prob-lems complicated by physical limitations, mental dis-abilities, and polypharmacy. Because of technologicaladvances in diagnosis and treatment, many people whoin the past would have succumbed to cancer, cardiop-ulmonary disease, or immunological disorders are liv-

ing longer but also experiencing the sequelae of treat-ment, for example the consequences of head and neckradiation. Because senior citizens are losing fewer teethprematurely, they will be conversely more at risk fordental problems later in life, leading to less reliance onthe full denture as a treatment modality and greater needfor more sophisticated prosthetic restorations.

In spite of the dramatic reduction in caries overthe past fifty years, profound oral health problems withsignificant morbidity and mortality still exist in the adultpopulation and the dynamic interplay between themouth’s microbial ecology and major systemic diseasesis being examined more closely. Periodontal diseases,rather than being perceived as a localized infectionwithout systemic repercussions, are now linked to avariety of life-threatening conditions includingnoninsulin-dependent diabetes mellitus, chronic degen-erative diseases such as ulcerative colitis and systemiclupus erythematosus, and heart disease. In the latter,preliminary investigations indicate that the risks of fa-tal heart disease may be substantially higher for per-sons with severe periodontal disease.19 In an effort toinvestigate the etiologic pathways underlying the peri-odontal disease-cardiovascular disease relationship, theNational Heart, Lung, and Blood Institute of NIH isnow sponsoring studies of the role played by biofilm-forming bacteria, which colonize the mouth, in the re-lease of pro-inflammatory mediators by white bloodcells which may, in turn, trigger stroke and heart dis-ease. The orofacial complex is also the site of approxi-mately 33,000 new cases of oral, pharyngeal, and na-sopharyngeal cancer annually, resulting in 8,000 deaths,making this category of cancers more prevalent than anumber of other carcinomas that have received sub-stantially more media and public attention, includingleukemia, pancreatic cancer, and cervical cancer.20

Dentists in the twenty-first century will also servethe oral health needs of an increasingly multiculturalpublic as the percentages of patients of Hispanic, Afri-can-American, and Asian heritage will continue to growin relation to the Anglo (non-Hispanic Caucasian) popu-lation. Overall, the growth rate in the United States hasslowed dramatically in the second half of the centuryto an all-time low of 10 percent per decade in the 1990sas compared to 30 percent per decade in the 1800s, 15percent from 1900 to 1940, and 19 percent in the “babyboomer” period of 1946 to 1966. The net increase inU.S. population since 1990 has been roughly 19 mil-lion, and 67 percent of this growth was accounted forby minority populations.18 By the year 2020, if currentbirth and mortality rates continue, 40 percent of the


children and adolescents in the United States will bemembers of minority groups versus approximately 25percent in 1980.21 Accordingly, patients may enter thedental office with different health care beliefs, motiva-tions, and expectations, and providers may experiencedifferences in disease prevalence as the patient pooldiversifies. For example, morbidity and mortality fromoral and pharyngeal cancer is roughly twice as high forAfrican-Americans as Anglos.11 A variety of studieshave revealed that members of minority populationsexperience greater risk for morbidity due to languagebarriers, lack of geographic proximity to health carefacilities, lack of reliable transportation, lack of healthinsurance and culturally based beliefs about health andillness.22, 23 The economic status of American familiesis also projected to decline over the next fifty years.Murdock estimates that the average household in theUnited States will have an income in 2050 that is $2,000less than in 1990 (measured in 1990 constant dollars).Further, the income differences between Anglo, Afri-can-American, and Hispanic households, which are cur-rently substantial (Anglo = $39,000; African-Ameri-can = $23,500; Hispanic = $25, 000), will continue tospread over the next fifty years.18 Thus, oral health inthe United States is becoming increasingly bi-polar, andpatient demographics are changing significantly withthe population becoming older, more ethnically diverse,and poorer. At one end of the oral health spectrum, sub-stantial dental problems exist in a sizable group of chil-dren living, primarily but not exclusively, in low-in-come communities. We say “not exclusively” becausedental services still account for 25 percent of all healthcare expenditures for children ages six to eighteen.12

In the middle of the spectrum, the majority of U.S. citi-zens have good oral health, a consequence of the re-search and prevention advances of the past fifty years.At the opposite end of the spectrum, a rapidly growingcohort of elderly patients will confront dental practi-tioners with intertwined and challenging dental andmedical problems. Overall, 9 percent of the U.S. popu-lation, or 22 million people, reported unmet dental careneeds in a study by the Project Hope Center for HealthAffairs based on the 1994 National Access to Care Sur-vey by the Robert Wood Johnson Foundation.24 Thisstudy revealed that 8 million more people reportedunmet oral health needs than people reporting medicalcare needs that were not met. Seventy-four percent ofthe individuals reporting unmet dental care needs con-sidered their problems to be serious. The researchersfound that ethnicity and socioeconomic status contrib-ute significantly to the lack of dental care. Twice as

many African-Americans (15 percent) reported unmetoral health needs as Caucasians (7.4 percent). Amongthose who wanted dental care but did not get it, 72 per-cent reported it was because they could not afford it,had no insurance, or could not find a dentist who wouldaccept their insurance.

The circumstances under which dentists providepatient care has also changed dramatically over the pastfifty years. In 1948, virtually all patients received careunder a fee for service arrangement. In 1997, an esti-mated 47 million people were covered by dental man-aged care plans, up 18 percent from 1996.25 By 2010,if current growth rates for DHMO (Dental Health Main-tenance Organization) plans remain consistent, it hasbeen predicted that 70 percent of dental patients willreceive care under some type of DHMO or PPO plan,while the remaining 30 percent will shift back and forthbetween fee for service and HMO/PPP plans based onprice and convenience or will receive dental care on apurely fee for service basis.26

How has the dental education community posi-tioned itself to respond to the evolution of oral healthin this nation over the past fifty years? Tedesco docu-mented dental education’s response using a number ofcurriculum reports over the past seventy-five years in-cluding the 1926 Gies Report, the 1935 Blauch Re-port, the 1947 Horner Report, the 1961 HollinsheadSurvey, the 1976 Higher Education Critique of theDental Curriculum, and several clock hour studies. Theconclusion? The dental education community has re-sponded to the winds of change with “some growth,and little change.”27-32

Dental Education’s Response toCurriculum Reform Initiatives

In addition to competency-based education, thereform agenda for dental education consists of approxi-mately a dozen recommendations including:

• decompress the curriculum by eliminating outdatedand peripherally relevant material,

• increase educational collaboration between den-tistry and the other health professions, featuringmore curricular emphasis on the interaction of den-tal and medical problems,

• redirect the curriculum toward production of oralphysicians,

• redirect basic science coursework toward disease


pathophysiology and oral medicine taught by prob-lem-based techniques,

• expose students to patients and their oral health andsystemic medical problems from the first days ofthe curriculum to the last,

• revitalize the science underlying clinical decision-making via evidence-based approaches,

• organize group practice teams in the clinical yearsto promote more continuity in faculty-student rela-tionships and expand peer teaching by studentsworking together in clinical teams,

• increase learning of clinical skills at chairside anddecrease time spent in preclinical laboratories,

• increase the use of community-based clinics as clini-cal training sites for students,

• include a clinical experience in the final year of thecurriculum, or a postgraduate internship year, whichreplicates the comprehensive care environment ofthe general dental practitioner,

• utilize technology to enrich student learning includ-ing informatics and operatory simulations,

• and, rededicate dental school clinics to serving theoral health needs of the public rather than prima-rily viewing patients as disposable and interchange-able educational material for students.

For the most part, these reforms represent ideasthat have been advocated for many years but only spo-radically implemented. The IOM study concluded that“the problem in reforming dental education is not somuch consensus on directions for change but difficultyin overcoming obstacles to change. Agreement on edu-cational problems is widespread. The curriculum iscrowded with redundant or marginally useful materialand gives students too little time to consolidate con-cepts or develop critical thinking skills. Comprehen-sive care is more an ideal than a reality in clinical edu-cation, and instruction still focuses too heavily on

procedures rather than on patient care.”9 The dental edu-cation reform recommendations, taken collectively,argue for a learning environment that encourages stu-dents to learn collaboratively, provides students withopportunities to practice application of newly acquiredbiomedical information by solving simulated or realpatient problems, fosters close and longitudinal con-tact between instructors and small groups of students,and provides learners with continuous contact withpatients, and their health problems, throughout the edu-cational program. These concepts are consistent withcontemporary educational theory and are based on theactive “inquiry-driven” learning that students use toconvert unorganized static information (e.g., data“sponged” from a text or a lecture) into the interlinkedchains of networked knowledge (e.g., information thathas meaning and perceived utility) that experts accessto solve problems (Figure 1).33,34,35 Advances in PETscan studies (Positron Emission Tomography) have pro-vided neurophysiologists with a technology capable ofmapping how the brain functions during complex cog-nitive, perceptual, and psychomotor tasks.36 These stud-ies indicate that expert practitioners (represented by theright side of Figure 1) have integrated neural networksthat facilitate instantaneous retrieval of chains of knowl-edge relevant to task performance or problem assess-ment. The novice (represented by the left side of Fig-ure 1), confronted with the same task or problem,struggles in a trial and error manner to assemble iso-lated bits of information (represented by the varioussymbols within the columns) because he or she lackspre-existing knowledge chains. Current theory indicatesthat problem-centered, “hands-on” collaborative learn-ing is a strategy that can help novices develop the knowl-edge networks needed for expert function.37

The rationale for these reforms, examples of theirapplication, proposals for future implementationand cautionary observations have been articulated byother authors, and it is not our intention to review thisliterature that addresses a variety of items on thereform agenda including: competency-based curricu-lum,38-39 maximizing the value of the basic sciencecurriculum,40-41 evidence-based health care,12,42-43 prob-lem-based learning,44-49 information technology,49-51

reforming clinical education,52-54 and the dentist’s rolein the overall health care system.55,56 The poster childfor many of these reforms in both dental and medicaleducation has been problem-based learning (PBL), par-ticularly in regard to enhancing the relevance of thebasic science curriculum, integration of the clinical andbasic sciences, and infusion of active learning (e.g.,

Figure 1. Novice and expert knowledge structure

Structure of novice knowledge Structure of expert knowledge

¡ u D ¡ u DD ⊗ ♥ D ⊗ ♥¨ N ∝ ¨ N ∝k Y @ 6 Y @t ℜ < t ℜ <

Vertical - compartmentalized Horizontal - networkedConfiguration of the

Smokestack Curriculum


students functioning in small collaborative learninggroups) into the curriculum. Assessment of the dentaleducation community’s reaction to PBL is instructiveand suggests, in part, why this reform and other educa-tional initiatives have made only modest inroads intothe predoctoral dental curriculum. The literature on PBLin medical school and other health professions is ex-tensive including several comprehensive reviews oflearning outcomes and attitudinal impact on studentsand faculty.57-60 A number of dental school applicationsof the PBL have also been reported.44,46,47,61 PBL has afour-decade track record of largely successful imple-mentation in health professions education, and the abil-ity of students to learn effectively in PBL programs isno longer seriously debated by individuals familiar withthe literature. On the other hand, there is no evidencethat PBL provides uniquely better educational outcomesthan traditional methods.62,63 Students and faculty inwell-orchestrated PBL programs often express favor-able attitudes, citing the energy of intellectual exchange,sense of personal involvement, and stimulation of dis-covery as they collaborate to solve the health myster-ies of the patient portrayed in the case, expressions ofexcitement about learning that stand in stark contrastto commentary about the tedious monotony of the lec-ture hall.64,65 Winston Churchill’s commentary on hisown education captures the positive attributes of PBLfor many students, “I hate to be taught, but I love tolearn.”5

Yet PBL has not captured the imagination of thedental education community to the extent it has in medi-cal school. Four factors may have contributed to PBL’sfailure to make significant inroads. First, traditionalPBL emphasizes the formulation of a broad-spectrumdifferential diagnosis, followed by systematic data col-lection to rule out pathogenic options. At its heart, PBLis a detective game designed to help students identifyproblems, retrieve data, and ultimately solve the mys-tery. As conceived at McMaster Medical School in the1960s, the purposes of PBL are to help medical stu-dents learn to play this detective game of diagnosis,the core task of the physician, and to help the studentacquire, in a palatable manner, scientific informationabout the normal structure and function of the humanbody and the pathogenesis of deviations from normal.The latter is accomplished by the trace-back method inwhich students are requested to trace a patient’s symp-tom back to underlying pathophysiological mechanismsin order to demonstrate their understanding of the dis-ease process. In a medical school PBL case, even rela-tively benign symptoms, such as cough, wheezing, or

fatigue can lead the student to consider pathophysiol-ogy pertinent to several organ systems and produce aninitial differential diagnosis that includes a wide arrayof items to be ruled out. The medical detective formatof PBL, focusing on diagnosis, may not be ideally suitedto the “traditional” dental school curriculum which hastended to emphasize the other end of the spectrum—treatment, via surgical and restorative methodologies,and determining how to deliver therapy in light of ana-tomical constraints, medical co-morbid conditions thatmay complicate treatment, and the patient’s financialcircumstance.

The second factor relates to how PBL has beenused in the traditional dental curriculum which, by vir-tually any standard, is the most dense (e.g., number ofcourses and clock hours) and consistently demanding(e.g., the number of exams, deadlines, and project/pro-cedural requirements) of all the health professions cur-ricula. Frequently, PBL is added to an already overlydense curriculum as a correlation course to help stu-dents tie together basic science and clinical concepts.No free time is created for students to do research be-tween PBL tutorials (e.g., to investigate questions aris-ing during case discussion); thus students perceive thecourse to be an extra burden that is further stigmatizedby having “homework assignments.” A well-recognizedPBL rule of thumb is that for every tutorial hour, stu-dents should have two hours of unprogrammed timeduring the regular 8 am-5 pm school day to researchquestions that evolve from analysis of the case.

Faculty concerns about the time and effort-effec-tiveness of PBL constitute the third factor in PBL’s slowdiffusion into dental education. In order to strengthenand diversify research programs, establish allianceswith other health professions, and offset stagnation instate appropriations, dental schools in the 1990s haveconverted a substantial number of teaching positionsinto primarily research-oriented positions. The remain-ing clinical teaching faculty are expected to devote in-creasing amounts of time to laboratory and clinicalcourses. Paradoxically, this has occurred at the sametime schools are being urged to incorporate more smallgroup learning into the curriculum which is perceivedto be more labor-intensive. Thus, department chairshave been hesitant to commit apparently dwindlingteaching resources to PBL.

The fourth factor relates to the nature of PBL it-self. The back and forth, sometimes unfocused, dia-logue that characterizes a dynamic PBL group as stu-dents vocalize and debate ideas, often in a circuitoustrial and error process, may appear messy and unpro-


ductive to many dental faculty who would prefer to “cutto the chase” and simply tell students how to solve theproblem rather than watch them flounder. Faculty dis-comfort with the PBL facilitator role and desire to leapinto the expert role are evident in all health professions.But from our experience, it appears to be more preva-lent in dental education, possibly because very fewdental faculty experienced PBL as students. Thus, theseemingly unstructured dynamics of PBL may not fallwithin the typical dental faculty member’s concept ofteaching or learning. In contrast, most medical schoolfaculty educated in the past twenty years probably en-countered PBL at some point in their training or per-haps even graduated from one of the thirty to fortymedical schools that employ PBL extensively. For thesereasons, PBL’s impact in dental education has been moreof a ripple than a wave, but we project a brighter futurefor PBL in dental education if it can be used within anappropriate curriculum structure.

New Directions in DentalEducation

In this section, we will review three future direc-tions for dental education which may make a differ-ence in the way dental students are educated and willthen describe a preliminary blueprint for a new type ofcurriculum built upon these ideas. The three directionsare: 1) developing a competency-based curriculum, 2)blending dental education into the mainstream of healthprofessions education, and 3) reform of the environ-ment in which clinical education occurs.

Competency-Based Curriculum(CBC)

Hendricson and Smith have described the threequestions that faculty must answer to develop a com-petency-based curriculum: 1) what knowledge, skills,and professional/personal values should the entry-levelgeneral practitioner possess? 2) what learning experi-ences will enable dental students to acquire these com-petencies? and 3) how do dental school faculty know ifstudents have attained these competencies—that is whatproof, or evidence, is needed to establish compe-tency?35,66 To date, dental education has focused exclu-sively on the first and third questions but paid scantattention to the second. In essence, the new Commis-sion on Dental Accreditation standards require compe-tency-based assessment, not competency-based educa-tion. A competency-based curriculum has three featuresthat are different from what most dental educators haveexperienced: 1) top-down planning based on analysisof the responsibilities of practitioners in the field, andforecasts of future societal needs, rather than bottom-up planning which focuses on what the disciplines wantto communicate to students; 2) a readiness-based modelin which students can progress at different rates throughthe curriculum than other students; and 3) a horizontalcurriculum structure in which students progress throughskill layers hierarchically organized by difficulty leveland characterized by tight time proximity between labo-ratory learning and clinical experience.

Top-Down PlanningGrussing first used the term “top-down planning”

to convey the idea that competency-based curricula are

Figure 2. Approaches to educational planning

Top - Down Assumed Competence

Analyze responsibilities and Certify completion of courses,

tasks of working professionals exams, and requirements

Define knowledge, skills, values Cover subject matter

to perform professional tasks

Provide focused learning • Faculty availabilityexperiences for competencies • Board examinations

• Textbooks

• Existing syllabi• Faculty preferences

• Departmental prerogative

• Tradition, convention & norms

Test competency performance

Allocate curriculum time based on:

Certified Entry Competence Bottom - Up


derived from the roles, responsibilities, and frequentlyperformed tasks of practitioners in the field.67 Grussingvisualized these roles, responsibilities, and tasks as the“top” or pinnacle of the educational mountain that stu-dents ascend to attain competency.

As depicted in Figure 2, faculty plan the curricu-lum by working down from these practitioner compe-tencies to create an interlinked sequence of learning

activities and assessments that prepare students for theseresponsibilities. The goal of top-down planning is tocreate an efficient pathway for the student, devoid ofmarginal and peripheral “nice to know” material, thatlinks competencies to subject matter and learning ex-periences, which, in turn, are linked to evaluations thatmeasure performance of these competencies. The out-come is a series of hierarchically arranged learning

Figure 3. Horizontal structure of competency-based curriculum


modules which start with universal foundation mate-rial (e.g., building blocks for all subsequent learning),and progress sequentially through more sophisticatedcompetencies. In contrast, most dental school facultyare familiar only with bottom-up planning which hasbeen the standard operational model for twentieth cen-tury higher education. In bottom-up planning, certainpre-matriculation courses are accepted by tradition asbeing suitable prerequisites for entry into the profes-sional program. Various courses are superimposed ontop of these prerequisites, with each discipline build-ing its own columns of courses, independent of otherspecialty areas, and resulting in a “smokestack curricu-lum” that resembles the left side of Figure 1. When allcourses conducted by all disciplines are passed, the stu-dent graduates. The assumption is that students, by theirown devices, will assimilate, retain, and integrate theinformation from all these courses and thus becomecompetent, with minimal outside assistance. Bottom-up planning helps faculty answer the questions, “Whatdo we want to teach students about our respective ar-eas of specialization?” In contrast, top-down planningencourages faculty to answer the question “What doour students need to learn?” Competency-based cur-ricula have been implemented with success in militaryand industrial training programs and have been em-ployed advantageously in some teacher training pro-grams, but have a checkered history in higher academia,including the health professions, possibly due to a mis-match with departmental structure, and also possiblydue to the traditions of academic freedom and indi-viduality embedded in the collective faculty conscious-ness. In the latter case, faculty may rebel against thetightly prescribed “lean and mean” curriculum associ-ated with CBC.

Readiness-Based ModelThe use of numerical requirements as a marker

of student ability is fundamentally antithetical to thecompetency-based approach. We have observed manydental schools attempting to craft an assessment pro-cess that maintains unit requirements, often renamedwith a more politically correct label, in coexistence withcompetency exams. In a competency-based curriculum,students and instructors jointly determine student readi-ness for “solo performance” competencyassessments (e.g., no helping hands from faculty). Onestudent could be ready after two to three patient en-counters, while another may require six to seven expe-riences. Dental schools desiring to meaningfully imple-

ment competency-based education will need to jetti-son the requirement-based philosophy that has been asignificant driving force for the clinical curriculum fordecades.

Horizontal Curriculum StructureCompetency-based curricula have a different

structure from traditional, discipline-based curricula.As previously noted, a bird’s-eye view of the traditional,discipline-based dental curriculum looks much like theleft side of Figure 1, a series of smokestacks represent-ing the courses of autonomous disciplines. In contrast,Figure 3 depicts, in simplified form, a bird’s-eye viewof a competency-based curriculum, derived from train-ing models in the military and industry.68 A brief re-view of the principle components of the CBC model inFigure 3 follows with observations about how it couldbe applied to the education of dental students. In a com-petency-based curriculum, students are often assessedpre-matriculation for their adaptability to the learningand evaluation methods employed in a competency-based program. After matriculation, students partici-pate in additional assessments to determine baselineskills in order to pinpoint the appropriate starting pointfor each student. Most, but not all, students will beginwith a “foundations” phase in which they learn patientcare skills and biological science concepts that serveas the universal underpinnings for all other areas ofperformance. Students are provided opportunities toapply these foundations by working with patientsthroughout this introductory phase of the curriculum.For example, in dental education, clinical skills uni-versally applicable to many areas of oral health carethat could be learned during a clinical foundations phaseinclude: patient assessment techniques (interviewing,intra and extra oral examination methods), charting,use of instruments, risk assessment, dental imaging,four-handed assisting, measuring vital signs, infectioncontrol techniques, periodontal instrumentation, localanesthesia, rubber dam technique, setting teeth, wax-ing, casting, impressions, prophylaxis/applying seal-ants, condensing amalgam and marginate, and basiclife support. Concurrent with acquisition of these foun-dation skills, students could be introduced to the worldof dental practice, including professional behaviors andethics, the dentist’s social responsibilities, basic ele-ments of oral health needs assessment, and professionalissues including patient and provider substance abuse,recognition of physical abuse/nutritional neglect, andinteraction/communication with other health profes-


sionals. The foundation biological sciences for thepredoctoral curriculum could include six thematically-integrated units: 1) normal and abnormal structure andfunction of cells, tissues, and organs, learned as an in-tegrated entity in gross anatomy, microscopic anatomy,neuroanatomy, physiology, and pathology modules con-ducted within a block course instead of a series of sepa-rate courses conducted without coordination; 2) nor-mal and abnormal development, structure, and functionof the orofacial complex; 3) normal and abnormal bi-ology of the oral cavity focusing on the dynamic inter-action among saliva, tooth structure, microflora, andmucosa; 4) concepts of assessment, prevention, andtreatment of orofacial diseases and abnormalities, whichwill provide a foundation for subsequent learning ofpatient treatment strategies in years two through four;5) biological interrelationships of the orofacial com-plex with other organ systems focusing on oral diseasesthat have clinically significant effects on general health,and the systemic diseases and medical conditions thatare risk factors for periodontal disease and other oralhealth abnormalities; and 6) an introduction to phar-macological and neurochemical receptor sites that willserve as the platform for pharmacotherapeutics, painmanagement, and behavioral management. Concurrentwith these core biological units, frequent clinical ex-posure to patients, particularly through history-takingand clinical examination, allows students to experienceaspects of the pathophysiology being introduced in bio-logical science coursework, to see variations in normalanatomy and function, and to observe the interminglingof dental and medical problems in patients.

After completion of competency tests pertinentto the biological and clinical foundations, students ac-quire increasingly complex competencies by movingthrough a hierarchy of learning modules. An importantfeature of the “hierarchical” CBC model is that inter-related pre-clinical (e.g., practicing basic technical com-petencies in a laboratory) and clinical experiences withpatients both occur within learning modules through-out the curriculum rather than the traditional system oflimiting laboratory work to the first half of the educa-tional program and clinical work to the third and fourthyears. Thus, in CBC, it is possible that even students inthe final phase of the curriculum may spend time learn-ing new skills in a laboratory. Students begin eachmodule with a simulation experience in which theylearn and practice the competency in a laboratory en-vironment. On the first day of the laboratory, studentsare assembled into learning teams of six to eight stu-dents led by an instructor who is assisted in the labora-

tory by a more advanced student who serves as a teach-ing assistant (TA). The team of students and instructormove together from the laboratory into the clinic toprovide continuity of instruction between laboratoryand clinic. A key principle underlying the horizontalCBC format is the continuous relationship of an expertpractitioner (instructor) with a small group of novicelearners in the tradition of the artisan-apprentice train-ing model perfected during the fifteenth and sixteenthcentury renaissance by the masters of various craftguilds. When students test-out of the laboratory phaseof the module, they move into the work environment(e.g., in dentistry, the clinic) and have opportunities toperform the procedure on patients within days of com-pleting the laboratory competency exam.

Competency assessment in the clinical phase ofthe module is often accomplished by the “triangula-tion” method which consists of three measurements ofdifferent aspects of competence. In the health profes-sions, this typically involves assessment of the student’sability to perform procedural skills, a written assess-ment of the student’s knowledge base and decision-making skills, usually involving analysis of case simu-lations, and the team leader’s overall assessment of thestudent’s performance including patient managementabilities, knowledge, technical skills, and professionaldemeanor. Many competency-based programs alsomeasure a student’s progress toward competency on alongitudinal basis beginning early in the program andcontinuing throughout the curriculum at periodic timeintervals. Chambers has described such a system fordental education.69 Upon successful demonstration ofcompetency, students enter a new module where theyare reorganized into new learning teams, meet new in-structors and laboratory TAs, and repeat the process.Students who do not demonstrate competency repeatthe module. The ultimate layer of the curriculum is anextended period of comprehensive, undifferentiated,practice in realistic on-the-job work settings. To gradu-ate, students must successfully complete competencyexams during the final curriculum layer that measureacquisition of key knowledge and skills and their abil-ity to demonstrate professional values.

A significant educational advantage of the hori-zontal competency-based curriculum is that the timedelay between initial exposure to skills in laboratorysimulations and the actual utilization of these skillsduring patient care is greatly reduced. In the traditionalvertical dental school curriculum, six to eighteenmonths may elapse between a student’s laboratory ex-perience with a skill and opportunities to perform the


procedure in the clinic. The literature on acquisitionand maintenance of complex procedural skills indicatesthat ability to perform dramatically erodes within threemonths of initial learning if not continuously practicedand fine-tuned.70,71 Additionally, in a competency-basedcurriculum, students work on one competency, or aninterrelated group of competencies, at a time beforemoving on to another area which is also consistent withresearch on the acquisition of high performance pro-cedural skills. In the discipline-based curriculum, stu-dents attempt to learn several different competenciessimultaneously—a sequelae of numerous departmentsadministering their own clinical programs in isolationof others. To our knowledge, no U.S. dental school hasimplemented a curriculum similar to the one depictedin Figure 3, although schools in other nations operateprograms with similar features, most notably theMalmo, Sweden, Dental School.

We think this model may be a good fit for thedental school curriculum of the twenty-first century,and from this point on, we’ll unveil a preliminary blue-print, in broad strokes, for a predoctoral program basedon competency-based techniques. The overall blueprintfor this twenty-first century curriculum appears in Fig-ure 6. First, we’ll review how the foundations phase ofthe CBC model has been applied in medical school andthen examine how it could be implemented in a dentalpredoctoral program.

A number of medical schools have introduced ahybrid curriculum combining traditional and PBL tech-niques in a format we have labeled the “AM-PMModel.”72,73 The AM-PM model varies from school toschool, but the basic structure involves these elements.Eight of the ten half-day blocks during the week arescheduled for learning experiences and two half-daysare left unscheduled. In the morning (AM), basic sci-ence courses are conducted with tighter thematic coor-dination than normally exists from 8 am to 12 noonfour days a week for a total of sixteen hours of contacttime. During two afternoons per week (PM), studentsmeet in small tutorial groups guided by clinical and/orbasic science faculty to analyze patient cases that re-quire application of concepts and information derivedfrom the biological science classes. The cases are writ-ten by teams of basic science and clinical instructorsbased on the AM syllabi. These case-based sessionsare typically two hours in duration (e.g., 1-3 PM), for atotal of four hours a week. The remainder of these twoafternoons are unscheduled so students can use the timeto research questions and issues arising during the tu-torials. On a third afternoon each week, the tutorial

groups participate in a physical assessment laboratoryto learn patient examination techniques related to theanatomical area or pathological mechanism being ad-dressed at that point in the curriculum. Students oftenpractice physical assessment on standardized patientsand receive corrective feedback from these individualswho are trained to represent health disorders and givesuggestions to students from a patient’s perspective, atechnique now being used more frequently in dentaleducation.74 Students also spend two half-days per weekat a clinical site conducting in-take interviews (chiefcomplaint, history of present problem, current medi-cations, and vital signs), observing residents andattendings “in action,” and assisting junior or seniorstudents with patient procedures. The remaining half-day is also left open which allows additional time forPBL-related research.

Application of AM-PM Model tothe Foundations Phase

The AM-PM format appears to be a viable modelfor the foundations phase of a dental curriculum. Toimplement the afternoon case tutorials, a class of eightydental students would require ten faculty tutors whocould be drawn from all departments, thus minimizingthe burden on any one department. The format of thebiological foundations phase of a dental curriculum isdepicted below with the biological science thematicunits indicated on the left and the titles of dental schoolcourses that traditionally comprise each unit on the rightside.

Foundations Phase of Twenty-first CenturyDental Curriculum

Dental School Courses ThatBiological Science Traditionally Comprise EachThematic Units Thematic Area

Development, structure, Gross anatomy, microscopicfunction, and abnormalities anatomy, neuroanatomy,of cells, tissues, and organs general pathology, physiology

(or pathophysiology),biochemistry

Normal and abnormal Gross anatomy/embryology,development, structure and growth and development,function of the orofacial dental anatomy, pediatriccomplex dentistry, occlusion, orthodon-

tics, TMD, craniofacialabnormalities, oral diagnosis,radiographic interpretation


Normal and abnormal Microbiology, biochemistry,biology of the oral cavity cariology, oral pathology,

immunology periodontics,nutrition, prevention,endodontics, oral diagnosis

Assessment, prevention, and Oral diagnosis, oral pathology,treatment of abnormalities preventive dentistry, commu-of the orofacial complex nity dentistry, public health

Biological interrelationships Oral and general pathology,of the orofacial complex oral medicine, systemicwith other organ systems disease, oral diagnosis,

treatment planning,gerontology, hospital dentistry

Pharmacological agents and Pharmacology, neuroscience,neurochemical receptor sites biochemistry

Clinical FoundationsFoundation clinical skills interviewing, oral examination,charting, use of instruments, risk assessment, dental imaging,four-handed assisting, measuring vital signs, infectioncontrol, etc.

Introduction to the dental profession and communitypreceptorships

Patient care experiences working in teams with third- andfourth-year students (one day/week)

The thematic unit on structure, function, and ab-normalities of human tissues and organs would includemodules on cell structure and function, metabolism andnutrition, microscopic and gross anatomy of tissues andorgans, and infectious processes and host response.After study of normal development, structure, and func-tion in this unit, students explore pathophysiology per-tinent to the major organ systems. The other thematicunits also incorporate material often presented in asmany as twenty different courses in the traditional, de-partmentally based predoctoral curriculum.

For the clinical foundations phase, two-thirds ofthe sessions in the PM clinical skills laboratory wouldbe devoted to the foundation dental skills described pre-viously. One-third of the lab sessions would be devotedto learning physical assessment skills pertaining to therest of the human body. The rationale for learning theseskills will be reviewed when we discuss strategies toblend dental education into the broader context of healthprofessions education.

The clinical skills laboratories also provide a fo-rum for introducing students to behavioral and psycho-social issues central to the relationship of patient andcare provider. For the one day of clinical experienceper week, the same ratio would be appropriate: 2/3 forassisting in the dental clinic and 1/3 in a medical pri-mary care setting performing patient work-ups. Con-current with the clinical skills laboratories, students

begin their socialization into the profession in the pre-viously described course, “Introduction to the DentalProfession,” which includes preceptorships in the of-fices of community practitioners and at communityclinics. A valuable resource for dental school facultycontemplating similar structural changes to the curricu-lum changes is Hilary Schmidt’s description of “les-sons learned” from recent efforts to integrate the teach-ing of the basic sciences, clinical sciences, andbiopsychosocial issues in medical schools.75

Structure of a Competency-Based Clinical Curriculum

To maximize the students’ learning opportunitiesand maximize utilization of dental school resources/facilities, we recommend an academic year consistingof forty-four weeks. As depicted in Figure 6, each clini-cal year can be divided into four ten-week competencymodules with two-week mini-modules scheduled afterblocks one (October) and three (March) for focusedpursuit of elective topics. We recommend that two ofthe mini-modules address oral health research and re-quire the student to conduct an evidence-based investi-gation of an oral health topic. For the remaining fourmini-module slots, students could choose from a vari-ety of options including an additional research mod-ule, clinical experiences in dental or medicalsubspecialties, comprehensive dentistry experience ina community-based setting, or patient care in theschool’s walk-in or emergency care clinic.

This plan will create a total of twelve ten-weekmodules in the sophomore, junior, and senior years withat least three of these modules (25 percent) devoted tocomprehensive dental care in a private practice envi-ronment (e.g., students function as care providers sup-ported by assistants, laboratory technicians, and patientcoordinators). Seniors would also serve one-half dayper week as teaching assistants in the foundation skilllabs for first-year students. Parenthetically, we are as-suming that hesitancy to further compound the prob-lem of dental student debt will ensure the maintenanceof the traditional four-year curriculum. The laboratoryto clinic ratio within the modules could be three weeksfor labs (at thirty hours per week) and seven weeks (alsothirty hours per week) for clinical work, although thisratio would obviously vary from competency to com-petency. We envision a variety of learning activitieswithin the modules including case-based conferences,retrospective case reviews in a CPC (Clinical Patho-


logical Conference) format, evidence-based literaturereview, CD ROM diagnostic modules to expose stu-dents to patient problems not frequently encounteredin the clinic,76,77 visits to practitioners’ offices and com-munity clinics, and unprogrammed time for studentsto investigate and report on issues in oral health carerelevant to the module competencies. In the clinicalphase of the module, eight half-day sessions per weekcan be scheduled for supervised development of com-petencies in patient-care situations. Students would alsodevote the remaining two half-day sessions per week(one day equivalent) to a vertically organized compre-hensive care clinic (CCC) comprised of freshman,sophomore, junior, and senior teams. During the sopho-more, junior, and senior years, students would partici-pate in a weekly interdisciplinary course, “ClinicalPractice of Dentistry (CPD),” addressing important pa-tient care and professional issues including manage-ment of pain, clinical pharmacology, dental econom-ics, health care systems, clinical pathology, dentalinformatics, and management of the dental practice.CPD would be conducted two hours per week, for ex-ample, on Wednesdays at either 8-10 am before clinicor 3-5 pm after clinic. The competency modules arearranged in a competency continuum and, just as anexample to stimulate thought, a hypothetical sequencemight include the modules in the following chart. Weare confident that dental educators will envision otherconfigurations for competency modules, but the keyprinciples in any arrangement are: 1) students prima-rily focus on one area of patient care at a time, and 2)the time interval between laboratory learning and useof skills with patients is as brief as possible.

Hypothetical Configuration ofCompetency ModulesSophomore Year Competency Modules

• Diagnosis, prevention, and treatment of periodon-tal disease, including an interdisciplinary rotationon surgical skills

• Restoration of dentition: amalgams and compos-ites

• Restoration of dentition: inlays, onlays, crowns(child and adult)

• Multidisciplinary health care (geriatrics, oncology,pediatrics, and ENT rotations) and public healthdentistry (five weeks each)

• Two mini-modules for clinical or research electives(two weeks each)

Clinical Practice of Dentistry = two hours perweek for: 1) Integrated Pain Management/Clinical Phar-macology, and 2) Economic Basis of Dental Care/Health Care Systems, scheduled in ten-week blocks.

Junior Year Competency Modules• Endodontics and interarch fixed restorations• Management of dysfunction/abnormalities of the

craniofacial complex (a multidisciplinary moduleaddressing growth and development abnormalitiesfrom childhood to adulthood)

• Removable restorations (partial and complete den-tures)

• Primary dental care (comprehensive care)• Two mini-modules for clinical or research electives

(two weeks each)Clinical Practice of Dentistry = two hours per

week for: 1) Clinical Pathological Conferences stress-ing recognition/treatment of oral pathologies and sys-temic interrelationships between oral cavity and otherorgan systems, 2) Clinical Pharmacology, and 3) Den-tal Informatics scheduled in eight-week blocks.

Senior Year Competency Modules• Oral surgery, management of trauma and emergen-

cies, and/or dental walk-in clinic• Implant dentistry and esthetic dentistry (five weeks

each)• Primary care (including a two-week hospital den-

tistry rotation)• Primary care (including a two-week practice man-

agement preceptorship/project)• Two mini-modules for clinical or research electives

(two weeks each)Clinical Practice of Dentistry = two hours per

week for: 1) the Dentist in Society (Professional Eth-ics and Jurisprudence), and 2) Management of the Den-tal Practice, scheduled in ten-week blocks.

Module scheduling will require a “lottery” startfor each curriculum layer. For example, using the hy-pothetical competency continuum outlined above, thesophomore year could involve dividing a class of eightystudents into three groups who would rotate among themodules. One-fourth (n=20) would start with the peri-odontics/prevention module, one-half (n=40) wouldstart with the restoration modules, which would be com-pleted as a combined semester-long block, and the re-maining one-fourth (n=20) would start withmultidisciplinary health care and public health mod-ule. The multidisciplinary health care component of thismodule would consist of rotations in geriatrics, oncol-ogy, pediatrics, and ENT. In the public health compo-


nent of this module, students would learn about dentalpublic health and epidemiological principles in semi-nars, provide preventive and educational services atvarious community sites, and complete a public healthresearch project involving field investigation (e.g.,documenting the oral health/medical problems of aspecific geographic community or population groupand developing a plan to enhance access to dental/medi-cal services). In the periodontics/prevention and resto-ration modules, students can be organized into learn-ing teams consisting of six to seven students, aninstructor, and a senior laboratory TA. Patient treatmentin junior year modules that may extend beyond the con-fines of a ten week rotation (for example, multi-unitfixed bridges or partial dentures) can be completed dur-ing the weekly comprehensive care days scheduledthroughout the academic year and/or during the Pri-mary Care Module depending on the student’s rotationschedule.

Blending Dental Educationinto the Mainstream of HealthProfessions Education

The IOM study recommended that “dental edu-cators should work with their colleagues in medicalschools and academic health centers to require and pro-vide for dental students at least one rotation, or clerk-ship, or equivalent experience in relevant areas of medi-cine, and offer opportunities for additional electiveexperience in hospitals, nursing homes, ambulatory careclinics, and other settings.”9 We view the dentist as ahealth care practitioner who has received specializedtraining in the assessment and treatment of diseasesand abnormalities of the orofacial complex, an ana-tomically and functionally defined region similar to theanatomic or functional parameters that establish prac-tice domains for other medical specialties/subspecialtiessuch as ophthalmology, dermatology, urology, andotorhinolaryngology.

Consequently, a fundamental “twenty-first cen-tury curriculum vision” question for dental educatorsto ponder is: Should the student training to function asan orofacial specialist receive an education that closelyparallels, and is better assimilated with, the predoctoraltraining provided for students preparing for careers inother areas of medical specialization? A number of fac-tors suggest to us that the answer is “yes.” With theadvance of research, it is becoming increasingly clear

that high morbidity diseases and abnormalities of theorofacial complex require multidisciplinary approachesto assessment and treatment including craniofacialanomalies with genetic etiology such as cleft lip andpalate, temporomandibular pain and dysfunction, oralmanifestations of HIV infection and AIDS, and oropha-ryngeal cancer. Recent studies linking periodontal sta-tus and cardiovascular disease and linking maternal oralhealth and the incidence of pre-term low birth weightinfants suggest the need for additional multidisciplinaryresearch and, ultimately, interventions in these areas.The growth in the number of elderly patients with medi-cal co-morbidity seeking treatment for oral health prob-lems will place dentists and physicians in more fre-quent collaboration to coordinate treatment for thispopulation. Serving the oral health needs of an expand-ing elderly population will also undoubtedly place den-tists in more frequent contact with assisted living fa-cilities and with allied health professionals who playimportant roles in the care of the geriatric patient inthese settings. The substandard health, including sub-stantial dental pathology, for millions of children liv-ing in our nations’ expanding “pockets of poverty,” willalso require coordination of effort with medical col-leagues and increase the dentist’s exposure to publichealth facilities and the community clinic environment.Advances in microbiology suggest that reducing ma-ternal reservoirs of mutans streptococci, preventingtransmission of bacteria from mothers to infants, andenhancing the child’s resistance to bacterial implanta-tion are viable approaches to primary caries preven-tion.12 Implementing these preventive measures andeducating the public about the infectious transmissionof caries will require teamwork between oral health careproviders and pediatricians.

Research in molecular biology, investigation ofthe genetic basis of disease, and breakthroughs in ge-netic engineering have also transcended traditional dis-ciplinary boundaries, blending the efforts of dental andmedical school investigators with basic scientists, acollaboration that will almost certainly lead to cross-disciplinary clinical trials of diagnostic techniques andtherapeutic regimens in the coming decades. Access tothe Internet and other sources of health informationhas enhanced the public’s awareness of disease pro-cesses, medications, non-pharmacological therapy, dietand fitness, nutritional supplements, and alternativemedicine, which in turn places pressure on all healthcare providers to stay abreast of developments across abroad spectrum of biomedical knowledge. And finally,academic health centers (AHCs) are struggling to de-


termine the “winning combination” for their managedhealth plans that will enable them to compete in themarketplace with other managed care organizations.Many AHCs hope to entice patient enrollments by capi-talizing on their ability to assemble an attractive pack-age of multidisciplinary service teams.

Given the uncertainties of core financing for uni-versity-operated clinics, it is imperative for dentalschools to demonstrate the “value-added” potential ofthe dental practitioner and the dental school-basedclinic, within an overall spectrum of health care ser-vices.78 The Blue Ridge Health Group, which consistsof academic health professionals, sociologists, econo-mists, and businesspersons, advises AHC administra-tors who are developing organizational structures ap-propriate to the changing face of health care. The BlueRidge Group recommends that: “AHCs must base theirmanagement structures and programs on the collectiveenterprise. Individual components of AHCs that cur-rently perceive themselves as independent and isolatedmust come to view themselves as an integral part of acommon enterprise, and must commit to collaborativeaccomplishment of common goals and objectives.”79

How can the education of dentists be blended withthat of other health professionals, particularly physi-cians-in-training? The IOM recommendation to add amedical clerkship, presumably in Internal Medicine,to the dental curriculum appears highly problematic.Clerkship directors in medical schools are already hard-pressed to locate appropriate training sites and adequatenumbers of university-based physicians or communitypreceptors for their own students, so the logistical fea-sibility of adding a sizable cohort of dental students tothe clerkship mix is doubtful. However, there are otherways to accomplish the goals of broadening and diver-sifying the dental student’s clinical experience, increas-ing student exposure to the disease processes he or shewill encounter among the patient population, and in-creasing exposure to members of other health profes-sions and their work environments. As we have pro-posed, a starting point would be to emphasize “wholebody” physical assessment in the foundations phase ofthe curriculum. Dental students should learn to con-duct a comprehensive “executive” physical examina-tion, including a full medical history and techniques ofregional system assessment (e.g., musculoskeletal, neu-rological, mental status), in the same depth as medicalstudents. Patients with chronic disease should be re-cruited to serve as subjects during physical assessmentlabs in the foundations phase of the dental school cur-riculum. Obtaining, writing-up, and presenting com-

prehensive medical histories of individuals with chronicdisease, at the same time as pathophysiologycoursework, will help orient students to the presenta-tion and natural history of medical diseases they willencounter in dental practice. The MultidisciplinaryHealth Care Module in the second year of our twenty-first century curriculum will provide dental studentswith a ten-week immersion in four areas where oralhealth care providers and other types of health care pro-fessionals are likely to interact on an ever-increasingbasis. Because of anatomic proximity and the cross-disciplinary nature of many diseases and abnormali-ties involving the head and neck, dental schools shouldpursue arrangements with an affiliated medical schoolto provide a two-week ENT rotation for dental studentsduring this Multidisciplinary Health Care Module. Den-tal students should also experience a two-week clinicalrotation in oncology because of the prevalence oforopharyngeal cancers.

Strong exposure to geriatric and pediatric healthissues will be an essential ingredient in the preparationof the twenty-first century dentist and thus should beincluded in this module. The geriatric rotation couldbegin with visits to the home environment of the eld-erly and exploration of the senior citizen’s world. Forexample, pairs of freshman medical students at the Uni-versity of Texas Health Science Center at San Antoniomeet with “senior professors” who are geriatric volun-teers willing to share their life experiences and medi-cal histories with students. During meetings which takeplace in the geriatric mentor’s private homes or in as-sisted living facilities, the mentors share with studentstheir observations about health, the aging process, com-munication problems, dealing with physical and men-tal limitations, and family issues. Students interviewthe mentor to gain an appreciation of the senior’s lon-gitudinal health history and learn about pivotal lifeevents from the point of view of the geriatric mentor.80

A similar program would be valuable for dental stu-dents, perhaps involving geriatric mentor visits bymixed teams of dental and medical students. Duringsubsequent modules in the clinical phase of training,dental students should provide dental care to geriatricpatients at the school clinic and at long-term care fa-cilities or older adult residential communities. The casemix of geriatric patients should include marginallyimpaired, functionally dependent, and the frail elderlyin addition to well patients, so that students encounterthe full spectrum of health status. Development ofmechanisms to support the training of dental geron-tologists should continue to be a priority for the dental


education community. The pediatrics rotation in theMultidisciplinary Health Care Module should exposethe dental student to the dynamic interplay between oralhealth problems and childhood diseases such as asthma,upper respiratory infections, cystic fibrosis, and nutri-tionally based developmental problems.

The two-week mini-modules scheduled twiceannually in the second, third, and fourth years of thepredoctoral program can also provide opportunities forcross-disciplinary clinical experiences. During mini-modules, dental students could acquire additional ex-posure to ear-nose-throat disorders, head and neck on-cology, care of the elderly, and pediatrics. The mini-module menu could also include experiences in othermultidisciplinary areas—for example, genetically basedcraniofacial anomalies, maxillofacial prosthetics, TMD,reconstructive surgery for facial trauma, oral manifes-tations of immunosuppression and other systemic dis-eases, substance abuse, and psychosocial/behavioralissues including neglect and physical/sexual abuse.

Building Alliances forMultidisciplinary Education

Creating the alliances with other components ofthe academic health center that are needed to imple-ment cross-disciplinary education will not happen over-night; in reality, we’re looking at a ten to twenty year“runway” to launch these collaborative activities. How-ever, medical-dental school alliances already exist inseveral well-recognized areas which suggests that ob-stacles are not insurmountable. The anesthesia and sur-gery departments in medical schools have a long his-tory of cooperation with dental school oral surgerydepartments in support of predoctoral and graduate-level training and the training of individuals for theD.D.S.- M.D. dual degree. At many academic healthcenters, dental and medical faculty collaborate activelyin the research and teaching activities of federallyfunded Geriatric Education Centers and provide jointstaffing for university-operated extended care treatmentcenters for the elderly. The staff of clinical centers es-tablished to treat craniofacial disorders and create max-illofacial prosthetic devices typically include both den-tists and physicians working in collaboration. All dentalschools have established hospital dentistry rotationsover the past twenty years, and several dental schoolsprovide four to six-week hospital externships for theirstudents. From our perspective, at least five long-termstrategies for cross-disciplinary “alliance-building” are

available: 1) establishing an institutional priority toactively compete for the federal dollars that supportmultidisciplinary research which historically has ledto cross-disciplinary teaching when “cutting-edge” bio-medical science is diffused into the curriculum; 2)cross-appointment of dental and medical school fac-ulty in areas with overlapping teaching, research, andclinical service domains such as Pediatric Dentistrywith Medical Pediatrics, General Dentistry/CommunityDentistry/Public Health Dentistry with Family Medi-cine, and Periodontics with Cardiology, Endocrinology,and/or Neonatal Care; we have observed that such cross-appointments often produce a beneficial “trickle-down”effect on the curriculum over the long term; 3) budgetre-direction in which schools purchase the services ofdepartments in other AHC components—this is a modelalready used by many dental and medical schools toacquire the faculty time and teaching expertise neededto implement the basic science phase of the curricu-lum; could a similar approach be used formultidisciplinary aspects of the clinical curriculum? 4)recruitment of dual degree faculty who have the breadthof training and experience to cross over traditional dis-ciplinary boundaries; many dental schools have D.D.S.-Ph.D. programs and employ individuals with dual de-grees to enhance the research and teaching missions ofthe institution; could a D.D.S.-M.D. interdisciplinaryspecialist be a viable mechanism for blending dentalstudent training with medicine? and 5) service exchangeprograms in which departments enhance each other’seducational or research programs in repayment for clini-cal services; for example, the dental school providesstaffing and equipment for mobile health vans or clin-ics operated by the medical school’s community out-reach health program and, in exchange, the medicalschool provides slots for dental students to participatein specified clinical electives, or, hypothetically, theENT department provides faculty to support physicalassessment labs for dental students in exchange for useof clinical research facilities located in the dentalschool. Dental schools committed to broadening theeducational experience of their students will need toproactively explore these and other strategies. Alliance-building strategies 1 (aggressively compete formultidisciplinary funding) and 2 (cross-appointment offaculty) may be reasonable starting points for this pro-cess in that they carry lower levels of threat and im-plied “turf-intrusion” than strategies 3 through 5.


Reform of the ClinicalEducation Environment

Implementation of the curriculum blueprint wehave described requires changes in the philosophy ofthe clinical curriculum, the role of the clinical faculty,and the way patients are managed. We recognize thatmany schools are implementing new approaches to theclinical curriculum including organization of grouppractice teams, strategies to provide a comprehensivecare experience for patients, and provision of bettersupport services for students. However, we also recog-nize there is not universal agreement among dentalschool faculty that these are positive changes. Newpatient or student-centered approaches to clinical edu-cation are struggling to gain acceptance in the face oftime-honored routines and departmental prerogatives.In this section, we will describe four systemic diseasesof the traditional clinical curriculum and recommendenhancements to the clinical learning environment thatsupport the competency-based model proposed in thispaper.

Systemic Problems of TraditionalClinical Education

The essence of traditional clinical education indental school was captured recently in this vivid de-scription: “Our teaching clinics are filled with student-clinicians to whom we provide a list of people in needof dental procedures. We tell the students to contactthese people, schedule them into a physical facility thatwe graciously provide in response to the student’s tu-ition payment, and complete a specific number of pro-cedural requirements within a designated time frame.We then allow these neophyte clinicians, having hadthe opportunity to complete a few previous procedureson plastic teeth, to simultaneously act as provider andassistant and flounder away. We keep the faculty closeby to look over their shoulders, give periodic advice,and request that they redo procedures that do not meetcertain criteria. At the conclusion of each procedure,we expect the student to transform from doctor to cash-ier, and then to appointment clerk, sterilization super-visor, and laboratory technician, so they continue theirjourney toward graduation.”81

Although this review of the dental student’s clini-cal environment highlights several curricular healthissues, the most critical systemic problem of clinical

dental education is the use of requirements to drive stu-dent activity. For many years, the dental school clinichas functioned unlike any other clinical training site inthe health professions in that it primarily serves theneeds of students in their efforts to complete proce-dural requirements, with patient care as a secondaryoutcome. But there has been discontent with this model.Ismail observed that “dental schools cannot continueto operate clinics like sandboxes for the future dentalprofessional,” providing dental care as a mechanism tomeet requirements for graduation.82 Galbally observedthat dental school clinics can no longer be “places wherethe apprentice dentist learns his/her trade, and whereeducation comes before service.”83 Dodge identifiedfaculty assumptions about student behavior that mayexplain support for requirement-driven clinical train-ing.52 He concluded that many faculty believe numeri-cal requirements and time deadlines are essential be-cause dental students are not adequately self-motivatedto obtain the clinical experiences necessary to reachcompetency and, without the threat of punitive incen-tives, students will not work productively or use chair-time wisely. In spite of faculty reservations about stu-dent motivation, several studies have demonstrated thatstudents operating without requirements are equally ormore productive than peers in a requirement-drivensystem, receive an equally diverse clinical experienceif not more so, perform as well or better on variousindices of clinical performance, and report lower lev-els of stress.52,84,85,86 The Commission on Dental Accredi-tation guidelines clearly stipulate that student educa-tional requirements are not to interfere with the care ofpatients.

A second systemic problem of traditional den-tal school clinical education is the lack of faculty role-modeling. Dental students rarely observe faculty treat-ing patients. Faculty are primarily perceived by studentsas checkers or graders because that is the role they havebeen asked to play in a clinic system in which the stu-dent, not the faculty member, has primary responsibil-ity for the patient. In contrast, students in the educa-tional programs of other health professions spendconsiderable time shadowing and assisting clinicalinstructors and advanced students, which providesopportunities to observe more experienced individualsin action as they care for patients.

The third systemic problem is the distracting anddisconcerting learning environment created when asmany as nine departments (e.g., Restorative, Prosth-odontics, Orthodontics, Oral Surgery, Endodontics,Pediatric Dentistry, Periodontics, Community/Public


Health Dentistry, Oral Diagnosis) simultaneously op-erate clinical training programs and literally competefor the student’s attention. Students devote an inordi-nate amount of time to noneducational tasks, bouncingfrom department to department attempting to figureout schedules, expectations, deadlines, forms that needfaculty signatures, payment procedures, charting pro-cedures, grading criteria, grading forms, and how tosign up for faculty coverage. In this environment, fac-ulty who are perceived by students to be good teachersare invariably individuals who help students cope withthe system and overcome logistical barriers, in effect,“running interference” for the students.

Lack of efficiency and patient-friendliness is thefourth systemic problem of traditional clinical educa-tion. This is a dangerous combination in an era whenAHC administrators are evaluating which clinical ser-vices will or will not enhance the attractiveness of theiruniversity health plan and also comparing the finan-cial viability of the AHC’s component schools. If thedental school and its clinics are to position themselvesas a magnet that can attract additional patient popula-tions to the academic health center’s medical plan andgenerate sufficient income to sustain operations, it isessential to create an efficient patient-first clinic op-eration that stresses service, convenience, flexibility,and quality. Given the projections of DHMO growth,dental student education is not complete without car-ing for patients in an environment that is service-ori-ented, and dental school clinics without a patient-first,service orientation will not be competitive with otherproviders of oral health care.

Clinical Curriculum EnhancementsPhilosophically and operationally, patient care

should be the top priority of the dental school clinicwith education as a by-product of delivering prompt,convenient, and high-quality patient care services. Themodular system integral to a competency-based cur-riculum should be implemented throughout the clini-cal phase of the student’s education. This format willallow students to focus on one set of competencies andone aspect of dentistry at a time without the time-con-suming and frustrating distraction of trying to deal withseveral clinical departments simultaneously. We agreewith Mulvihill’s recommendation that the school’s pa-tients should be the responsibility of the faculty, notthe students.56 Faculty should assume primary respon-sibility for the appropriateness, quality, and timelinessof care provided to patients and should actively mentor

students in patient management techniques. This ar-rangement will require collaboration between facultyand students to triage patient status, develop plans, anddeliver the care patients need, a process that will in-crease opportunities for students to learn from faculty.It will also allow students to observe faculty in a careprovider role. Resources will need to be devoted to pro-fessional development programs that prepare facultyfor these new roles. The outcomes of the Robert WoodJohnson curriculum innovation project and evaluationsof other instructional improvement efforts demonstratethat preparation of faculty to assume new academicduties is vital to successful implementation and main-tenance of the reform.87,88,89 The structure and charac-teristics of effective professional development programsin the health professions for improving teaching prac-tices have been studied extensively. Cohen andWilkerson provide guidelines for conducting facultydevelopment programs that should assist dental schoolsin establishing this essential part of curricular renewal.90,91

Clinical requirements and daily grades should beeliminated. With the sophisticated computer softwarepackages available today, there should be no reason notto implement an “invisible hand” system that monitorsstudent productivity and performance and indicatesareas in which the students need additional experiences.Daily grades require tremendous effort to collect, en-ter into databases, and tabulate, but they add very littleto our understanding of student competence since themean scores for all students almost always fall withina very narrow range. Well-prepared and poorly preparedstudents often have very similar clinical averages basedon daily grades. Daily grades also have been shown tocorrelate poorly with clinical practical examinations inwhich the student must show what he or she can dowhen working alone.92 As a substitute for daily grades,student assessment should be based on the three trian-gulation data sources previously discussed: 1) the teamleader’s evaluation of the student’s longitudinal progressduring the module, including patient management, tech-nical skills, and professional demeanor, 2) competencyexaminations, and 3) a written, case-based examina-tion for each module prepared in the same format asthe cases in part two of the dental national boards. Thepatient screening process should be modified so stu-dents come into contact with more patients with medi-cal co-morbidities and more frail or elderly patients.More emphasis should be placed on promptly resolv-ing the patient’s immediate oral health problems andreducing the number of treatment planning appoint-ments to the number that patients would tolerate in pri-vate practice.


We recommend that students spend at least oneweek per year providing dental care at an off-campuscommunity site, particularly in underserved areas. Tele-conference technology can link students at remote clini-cal sites to the dental school so they can participate inconferences and meetings. Team leaders of the mod-ules can also consult with community site students onpatient care issues via the same technology. Town-gownissues always cloud discussion of dental school move-ment into the community, but we believe it is in thebest long-range interest of schools and students to pur-sue opportunities to diversify clinical training environ-ments. Other AHC components are pressing ahead withefforts to provide a continuum of services and educa-tional sites that include high-technology tertiary care,ambulatory outpatient clinics, day surgery facilities,community primary care clinics, rehabilitation services,mobile clinics, and home-based care.56 In another reach-extending mechanism, AHCs are also creating or join-ing hospital and clinic consortiums in various locationsthroughout their states, thus expanding the school’s ser-vice area and patient pool as well as creating more clini-cal sites for students and residents.79 If dental schoolsare to build and maintain professional relationships withother health professions and improve public access toservices, they “must be willing to migrate from the rela-tively peaceful and often artificial isolation of studentand faculty dental clinics.”56

The Sociology of Change inDental Schools

After assessing the wreckage of a failed attemptto revise the curriculum, a medical school dean oncesuccinctly captured the challenge of reform: “It is notenough to have good ideas. There are other factors thatare much more powerful.”93 To explore these “otherfactors,” we’ll return to Churchill’s adage—“the winds

of change are blowing and we lean into them with equalmeasures of anticipation and dread.” It has been ourexperience that the winds of change are likely to stimu-late more dread than anticipation among faculty andadministrators in higher education institutions. Goffeeand Jones and Berquist studied the culture of universi-ties and the values of faculty as the basis for analyzingadaptability to change, and Delbecq examined the ex-tent to which health center administrators valued team-work and collaboration.94-96 They observe that univer-sity faculty value independence, desire autonomy, anddo not value collaboration, but have a strong need forjob security and insulation from risk. Goffee and Jonesdepict the organizational culture of an institution on amatrix with two axes—solidarity (defined as the cohe-siveness of purpose among components of an organi-zation) and sociability (refers to the interpersonal rela-tionships among individuals working in theorganization). The levels of solidarity and sociabilityamong the institution’s members can be high (strongsense of solidarity and much sociability) or low (weaksolidarity and minimal effort at sociability). Goffee andJones conclude that “university faculty, identifyingmore strongly with their disciplines than with the uni-versity itself, typically lack solidarity. Their interper-sonal relationships (sociability) may be distant as well,placing the university low on both solidarity and so-ciability,” thus making the university culture unusuallyresistant to change.94 Delbecq found that administra-tors of medical centers placed low value on teamworkamong disciplines and that conventional rationales forcollaborative effort were unsuccessful motivators in thisenvironment. Dentists have been described as cautious,and conservative, valuing orderliness and conformity,with a desire to control events.97 Not surprisingly, the

Figure 4. Response to institutional change

Denial Self-protective state to avoid being overwhelmed

Resistance Mourning & distress; passive-aggressive resistance

Acceptance Inevitability of impending change is recognized

Bargaining Attempts to piecemeal or sequester the new plan

Exploration Future-focused thinking about how to integrate newplan into mainstream of institution

Commitment Proactive efforts to make new plan work effectively

Comfort Plan is no longer “new” but is perceived as routineand “our way”

Figure 5. Approaches to curriculum development

Mount Olympus “This is what we’re going to do!”

Preemptive Strike “Oh, by the way, we now have a new clinical ...”(Sneak Attack)

Attilla the Hun Mandated across-the-board percentage cuts(scorched earth policy)

Fire-Fighting The most common form of curriculum changebut basically “pothole-filling”

Departmental Produces minimal reform due to effect ofReview “fox guarding the chicken coop”

Interdisciplinary Curriculum plastic surgery (nip & tuck) due toPeer Review faculty hesitancy to be critical

Assessment and Parallels scientific decision-making processDiagnosis Model (See Figure 7)

Competency-Based Top-down process linking practice behaviorsPlanning to competencies and then to subject matter

20

American Association of D

ental Schools

Figure 6. Proposed twenty-first century curriculum


independent yet cautious nature of faculty is reflectedin the overall structure of higher learning institutionsincluding dental schools. Hutchins’s observation thatuniversities are a series of separate departments heldtogether by a central air-conditioning system remainsan apt description of the discipline-based structure ofdental and medical schools in the 1990s.93 Ebert andGinzberg describe medical schools as “a confederationof semi-autonomous fiefdoms” which seemingly existto compete with each other for treasure (institutionalresources), territory (office, laboratory, and clinicspace), and political influence (curriculum time).98 Ourexperience suggests that the fiefdom analogy is appli-cable to the majority of dental schools. If, as JuliusCaesar observed, “commerce follows transportation,”then curriculum follows the school’s organizationalchart.99

Given these factors, resistance to change in theuniversity and health center environment is the normrather than the exception. Dental education is not alonein its inability to institute meaningful reforms. In 1989,Samuel Bloom published a classic case-study of medi-cal education: “Structure and Ideology in Medical Edu-cation: An Analysis of Resistance to Change.”100 Bloomreviewed the myriad efforts since 1920 to improve thecontent and structure of medical education and ob-served that the process was characterized by “reformwithout change,” a conclusion echoed by Christakiswho assessed the impact of nineteen national-level re-form efforts this century.101 Bloom and Christakis con-cluded that organizational structure and the cultural en-vironment of the institution are major barriers toeducational revitalization. Several studies have alsolinked curriculum reform failures to the power imbal-ance between academic departments that control bud-get and personnel assignments and school committeescharged with curriculum review and development.102,103

The latter have responsibility, but no budgetary or per-sonnel control to ensure recommendations are imple-mented. On the positive side, Bussigel’s case-historiesof curricular innovation demonstrated that forceful lead-ership by the dean can mitigate the effects of this powerimbalance.104 The goal of the Robert Wood JohnsonFoundation’s curriculum innovation project which pro-vided funding to eight medical schools was to “intro-duce new methods of instruction into curricular revi-sions and to find innovative ways to support learningin students’ preparation for practice in the 21st cen-tury.”75 Assessment of curriculum innovations in theseschools reinforces the critical role of the dean in thepivotal stages of reform: visualizing the need for

change, selecting appropriate leaders to guide the re-form effort, deflecting departmental resistance as thereform plan takes shape, and standing up for the re-forms in “crunch-time.”105

The process by which educational institutions re-spond to impending changes in policy, resource allo-cation, or structure is also predictable. Reform effortsin institutions with complex infrastructures proceedthrough the phases represented in Figure 4.35,106 Mostreform efforts fail to move beyond the denial or resis-tance stages, particularly when they are not provokedby a galvanizing event that reflects poorly and publiclyon the institution. Reforms may reach the bargainingstage if leadership persistently focuses attention on theproblem and articulates a viable solution (e.g., a neworganizational reality), a process known as “realityframing.”107 Levine identif ied enclaving andpiecemealing as effective bargaining strategies thatblock educational innovations.106 Reforms often areenclaved, or quarantined, as a detached “special” pro-gram that sequesters reformers away from convention-ally minded faculty. In piecemealing, departments se-lectively adopt certain components of a reform packagewhile ignoring less-agreeable aspects. Becauseenclaved or piecemealed reforms can be implementedwithout disrupting discipline boundaries, departmentswill bargain-down to these limited reforms that havenegligible impact on the school as a whole, aminimalization process leading to Bloom’s “reformwithout change.”

Enhancing Efforts to Reformthe Curriculum

Figure 5 reviews approaches to management ofcurriculum reform we have observed over the years.Draconian strategies (e.g., Mount Olympus, Preemp-tive Strike, Attilla the Hun) are tempting but are likelyto produce passive-aggressive resistance and subtlesabotage. Imposed reforms erode when the CEO thatdictated the change departs the institution. The RobertWood Johnson curriculum innovation project, and ourown experience, indicates that educational reform ismore likely to evolve from a well-managed and broadlybased review.87 Accordingly, we believe the followingrecommendations will help future curriculum reformefforts:

1. The AADS should establish a task force to createand disseminate models of predoctoral curricula that


incorporate the various reforms. Most dental schoolshave operated the standard discipline-based curricu-lum for decades (yr 1 = basic science lecture courseswith a few preclinical labs; yr 2 = preclinical lectureand lab courses, a few basic science courses, and aget-ready for clinic experience; yrs 3 and 4 = pri-marily clinical, often divided into specialty-focusedand generalist-focused components). Few facultyhave experienced educational programs that are notclose approximations of this standard model. Thisis a limiting factor when seeking new approachesbecause teachers teach the way they were taught.

2. The AADS should develop training workshops thatdemonstrate how to orchestrate a curriculum remod-eling process. In consulting with dental schools overthe years, we have encountered stories of failed re-form efforts that produce faculty cynicism about cur-riculum renewal efforts. Often, the individualsplaced in charge of curriculum overhauls have noexperience with such endeavors. One common short-coming is the failure to base the review on a modelthat identifies data collection, analysis, planning, andimplementation steps and which can be used to com-municate the overall process to the varied constitu-

Figure 7. Monitoring and revising educational programs


encies of the dental school community. For example,we have found that the cyclical “assessment and di-agnosis” curriculum review process in Figure 7 isreadily understood by faculty because it correspondsto the sequential scheme of scientific inquiry.

3. One of the barriers to curriculum reform is that thecharacteristics of the desired product are vaguelydefined at the onset, or not defined at all. To avoidthis, a broadly based faculty committee should cre-ate guiding principles for the predoctoral curricu-lum prior to commencing the remodeling effort.These guiding principles should describe the char-acteristics of an ideal or “gold standard” curricu-lum which can serve as outcome measures to evalu-ate the success of the remodeling. These principlesshould be communicated to the faculty for discus-sion, modification and eventual approval by appro-priate faculty governance groups, and endorsementby the chairs of the school’s academic departments,again, for emphasis, before starting curriculum re-view.

4. School administrators who launch curriculum re-form should articulate the goals of the voyage theyare asking faculty to make. Is the outcome to repairspecific problems (e.g., pothole filling), to conducta comprehensive review of the entire program (e.g.,the executive physical), or to create a new curricu-lum without active review of the current program(e.g., the ground-zero approach)? Conflicts occurwhen the scope of remodeling is not consistent withthe expectations of school administrators.

5. Bloom and Magill observed that the discipline-basedstructure of health professions educational institu-tions is a direct descendent of the organizationalstructure of the German research university as itemerged in the latter half of the nineteenth cen-tury100,108 (e.g., curriculum follows the organizationalchart). In 1870, subdividing university resourcesalong purely disciplinary lines made sense becausecross-disciplinary research was not even a consid-eration given the dim awareness of biological mecha-nisms underlying human health and disease, virtualignorance of bacteriology and virology, and the un-sophisticated technology available to investigate bio-logical questions. However, as dentistry and dentaleducation enters the twenty-first century, does theorganizational structure of the nineteenth-centuryGerman research university still provide the mostappropriate environment for oral health research andfor educating oral health care professionals? Aca-

demic administrators will need to address this criti-cal question as part of the curriculum reform pro-cess.

6. A special issue of Academic Medicine reviewed thepreliminary outcomes of the Robert Wood Johnsoncurriculum innovation project and provided obser-vations about the process and politics of curriculumreform.72,75,87 We selected ten “lessons learned” fromthat project that are pertinent to the task at hand fordental education:

• How did change begin at these schools? It beganwith a vision articulated by a small group.

• Those who envisioned innovations were not alwaysthe best people to win consensus.

• Implementing a well-integrated curriculum requiresstrong leadership and overcoming departmentalbarriers.

• Leaders played an important role by assuring in-centives and rewards for faculty members involvedin the change process.

• Successful leadership strategically bypasses chal-lenges. Pockets of resistance from faculty membersand departments related to the innovation are oftenbest addressed at a later date when the innovationhas been institutionalized and the resistance iso-lated.

• Consistently, changes were most successful whenthey reflected broad-based ownership of the inno-vations. Most schools used several strategies to at-tract broader faculty ownership and greater creativeinput—case discussions, forums, symposia, dem-onstrations of learning methods, and ongoing dia-logue about education.

• All programs found students helpful to the changeprocess; because students experienced the entirecurriculum, their thoughtful feedback and sugges-tions were invaluable.

•· The educational development of faculty membersis an essential ingredient in significant curriculumreform.

• Authority, accountability, and allocation of re-sources for education sometimes became confusedwhen a traditional departmentally controlled cur-riculum became interdisciplinary.

• Attempts to centralize the budget for education ledto resistance among chairs who were accustomedto flexible use of funds that had been earmarkedfor education.


We’ll conclude with a reminder from the sixteenthcentury:

There is nothing more difficult to take in hand,more perilous to conduct, or more uncertainin its success, than to take the lead in the in-troduction of a new order of things—becausethe innovator has for enemies all those whohave done well under the old conditions . . .but only lukewarm defenders in those who maydo well under the new.

—Niccolo Machiavelli, The Prince109

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Documents

Future Directions in Dental School Curriculum, Teaching