IGNITING MINDS THROUGH STUDENT SELF …9582a3b18a6394d0bf2a-2047e15e84f2d475a3bf2d6b165dd80c.r4.cf2.rackcdn…IGNITING MINDS THROUGH STUDENT SELF-DIRECTED GROUP LEARNING: Integrated

IGNITING MINDS THROUGH STUDENT SELF-DIRECTED

GROUP LEARNING:

Integrated Problem Sessions (IPS)

BU Henry M. Goldman School of Dental Medicine

Cataldo W. Leone, DMD, DMSc Professor of Periodontology Associate Dean for Academic Affairs

Carmen D. Sarita-Reyes, MD Assistant Professor of Pathology and Laboratory Medicine

Carol T. Walsh, MA, PhD Professor of Pharmacology and Experimental Therapeutics; Vice-Chair for Education

*Monica A. Pessina, MEd, PhD Assistant Professor of Anatomy and Neurobiology

*Elizabeth R. Whitney, MSPT, PhD Assistant Professor of Anatomy and Neurobiology

*joint presentation

Outline

n  Introduction n  Rationale n  History n  Guiding Principles / Educational Philosophy n  Δ Formats

n  Representative Examples

n  Learning Outcomes

n  Q & A / Open Discussion

Henry M. Goldman School of Dental Medicine

Rationale (i.e., the landscape)

n  Premise: Dentistry/Dentists today ≠ tomorrow n  Desired outcome: Meaningful student learning (by adults) n  Andragogy tenets

n  Principles of learning >> methods of teaching n  Teaching involves active, self-directed learning n  Δ learner autonomy requires Δ teacher guidance n  Learning process is dynamic & evolves over time

n  Belief that “ignited” students learn >> “unignited” peers n  Quicker uptake n  Deeper understanding n  Enhanced retention


Rationale (i.e., the landscape)

n  Planned/structured approach >> serendipity n  Part-and-parcel with “the curriculum” n  Incorporates students’ educational progression n  Leads to self-direction, self-discovery, self-motivation

n  Questions being asked: n  What do we teach ?

§  Evidence basis for maintaining/refining existing content ? n  How do we teach ?

§  Faculty development & re-education about education ? n  How do students learn ?

§  Millennial generation vs. other students ? n  Can teaching & learning become more efficient ?

§  Maximize space, time & personnel


§ Ensure that the predoctoral curriculum is relevant § NIH Institute of Medicine Report (1995): Dental Education at the

Crossroads § ADEA Commission on Change and Innovation in Dental Education

Report (2009): Beyond the Crossroads § Pew practitioner competencies for the 21st Century § Competencies for the Dentist of the 21st Century § Evidence based practice recommendations

§ Teach in ways consistent with how students best learn § Integrated Curriculum § Active Learning § Targeted Reinforcement and Building (spiral >> linear approach)

§ Document program learning outcomes § Do students actually learn what we think they will learn ?

Ongoing Academic Charge: Excellence in Educational Content, Delivery & Outcomes


Educational Challenges

n  Need for defined & measurable outcomes n  Integrated instruction

n  Within biomedical sciences (where IPS started) n  Across biomedical, behavioral & clinical sciences

n  Engaged students n  Evidence-based graduates

n  Resource constraints n  Large class size (117 DMD + 82 Adv Stnd + ~20 post-bacc) n  Curriculum (face) time n  Faculty availability n  Classroom space

n  Faculty (& student) buy-in


Educational Solution

n  “Integrated Problem(s) Sessions” (IPS) n  ADEA CCI Liaison’s project n  Feasible approach to adopt n  Both graded and ungraded exercises n  Allows economy-of-scale in didactic instruction n  Supplements traditional lecture-based instruction n  Theme or “ribbon” thru 11 courses in DMD years 1-3 n  Fosters meaningful interdisciplinary collaboration


History

n  2006/7- Pilot implementation in Dental Physiology Course (1st year) n  Evaluation/Assessment by Academic Dean; Refinements in format

n  2008- Implementation in Dental Biochemistry Course (1st year) n  Continuing review

n  2009/10- Implementation in: n  Oral Biology I (2nd year) n  Dental Pharmacology (2nd year) n  Microbiology/Immunology (1st year) n  General Pathology (1st year)

n  2010-2013- Implementation in: n  Anatomical Sciences I (1st year) n  Anatomical Sciences II (1st year) n  Oral Biology II (2nd year) n  Oral & Maxillofacial Pathology (3rd year) n  Pediatric Dentistry (3rd year)


Guiding Principles/Educational Philosophy

n  Goals/Objectives n  Ignite & unlock ! n  Self-directed learning groups (faculty-guided) n  Faculty-focused teaching << student-centered learning n  Consistent with different course content, instructor

preference & students’ progressive knowledge

n  Flexible process n  Students are assigned and/or volunteer n  Exercises are ungraded and/or graded (% or bonus) n  Variable clock hours per course (5-20% total hours) n  One size does not fit all (∴Δ formats, to be discussed)


Guiding Principles/Educational Philosophy

n  Desired outcomes n  More active/less passive learning (& teaching) n  Students become the teachers n  Faculty become the facilitators n  Administrators become happy


∆ Formats

n  Multiple formats encouraged; again, consistent with

different course content, instructor preference & students’

progressive knowledge

n  Case/problem-based scenarios n  Journal club-type presentations/critical reading of the

primary literature n  Interactive Q & A and real-time search of evidence


n  Cases/topics, questions & learning objectives predefined by course faculty n  Students begin school w/ Δ experiences/skills in formal

presentation and evidence-based learning n  Preparation

n  Students meet with faculty facilitator 1-2 times beforehand §  Promotes good understanding of the cases §  Allows correction of any incorrectly understood material

n  Students will have practiced their presentation in advance n  Audience provided faculty-approved handouts and lecture slides

n  In-class session n  Students take turns presenting different aspects n  Audience is to be engaged (presenters get creative!) n  Possible quiz and follow-up discussion


Structured Cases Format

Literature Review / Journal Club Format

n Recognizes students’ learning continuum n  Sessions build upon prior/current educational content

n  Allows students in-depth study of selected course content

n  Student-directed: students organize their strategy and assign component tasks among themselves, by consensus

n  Faculty-guided: input/clarity/clarification

n  In-class session n  Published articles presented in class by a group of 4-6 students

§  “talking head,” “chalk talk” and/or PowerPoint® modalities n  Voluntary

§  Presenters & audience receive bonus points towards their grade §  Applicable content included on examinations


Interactive Q & A Format

n  Pre-work/homework, as warranted n  Problem set provided & due before class (if used) n  Graded (flexible)

§  Thought process >> actual answers

n  In-class session n  Problem/case scenarios w/ questions

§  Questions (open- or close-ended), w/ or w/o audience response system (“clickers”)

§  “Just-in-time” search for evidence n  Group discussion

§  “Flipped classroom” approach §  Promotes discourse/debate

n  Real-time reality check on learning n  Homework re-submission possible


Outline

n  Introduction

n  Representative Examples n  Hybrid Structured Case & Literature Review

§  Drs. Pessina & Whitney




Overview of Anatomical Sciences ✦ Course Faculty

✦ AS-‐I (Fall Semester) ²  Histology ²  Neuroanatomy

✦  AS-‐II (Spring Semester) ²  Embryology ²  Gross Anatomy

Evolu5on of IPS Structure Based on Student Feedback

ª  Ini9al format: In-‐class review of journal ar5cles ²  Pros: reinforce course material in the context of a journal ar:cle;

did not overwhelm students with outside assignments ²  Cons: limited to ar:cles selected by faculty; limited :me to analyze and

integrate material ²  Feedback: students reported the short :me-‐frame did not allow full

integra:on of journal ar:cle material

ª  New format: Pre-‐assigned clinical cases with review ques5ons ²  Pros: reinforce course material in the framework of a clinical case;

student-‐centered journal ar:cle retrieval and review ²  Cons: par:cipa:on in case presenta:ons is limited to student

volunteers (though ques:ons are included on wriEen examina:ons) ²  Goal: ignite students’ curiosity using cases that demonstrate how

course material is directly related to and applied in dental prac:ce

AS-‐I: Histology Modules and IPS Cases ✦  Module I and II : Histology

²  Lecture content: histological principles and techniques; epithelium and glands; connec:ve :ssue; muscle; cardiovascular and blood; integument; endocrine, urinary, immune, respiratory and diges:ve systems; nervous :ssue; tooth development and histology

Ø  IPS case: 15 year old boy with osteogenesis imperfecta-‐type I; his mother inquires about the possibility of orthodon9cs for her son

Ø  IPS case: 81 year old pa9ent with complaints of dry mouth and difficulty swallowing.

Ø  IPS case: 39 year old pregnant female with Type-‐II DM and no dental care x 15 yrs.

Ø  IPS case: 53 year old female pa9ent inquires about having seven mercury fillings removed and replaced because of concern of mercury poisoning

Detail of IPS Case Histology Modules

A healthy 53 year-‐old female pa9ent contacts your office and inquires about having seven mercury fillings removed and replaced because of concern of mercury poisoning from dental fillings. ª  Students answered a series of ques9ons using course resources and

at least 3-‐4 ar9cles (original research, review ar9cle, case report).

1.  Summarize at least 3 different histological procedures that are discussed in the literature.

2.  Name three organs or organ systems have been studied regarding this topic and explain the ra:onale for studying these organs/systems.

3.  Present histological images from the literature and describe the structures visible in each image.

Histological Techniques and Organ Systems:

ª Students discussed a study using scanning electron microscopy to assess the effect of mercury on the re:na of :gerfish ²  Mela M1, Grötzner SR, Legeay A, et al. Morphological evidence of

neurotoxicity in re9na aVer methylmercury exposure. Neurotoxicology. (2012)

ª Using autometallography, this study inves:gated mercury in cerebral blood vessels of animals with prenatal mercury exposure. ²  Pamphlet R. Mercury Vapor Uptake into Nervous System of

Developing Mice Neurotoxicology and Teratology. 23.2 (2001)

ª Using cold vapor atomic absorp5on in cadavers, this study examined the correla:on between number of amalgam fillings and mercury levels in: cerebral cortex, renal cortex, pituitary gland and thryoid gland ²  Gianpaulo G.Dental Amalgam and Mercury Level in Autopsy

Tissues American J Forensic Medicine & Pathology. 27.1 (2006): 42-‐45.

Summary of Student Learning

hEp://www.uwm.edu.pl/kchem/mercury/aas_method.html

Summary of Student Learning (cont’d)

Students present histological images from the literature and describe the structures visible in each image.

Image source: Pamphlet R. Mercury Vapor Uptake into Nervous System of Developing Mice Neurotoxicology and Teratology. 23.2 (2001)

AS-‐I: Neuroanatomy Modules and IPS Cases

✦  Module III and IV _ Neuroanaotmy ²  Lecture content includes: CNS & ANS overview and organiza:on; sensory

and motor pathways; cranial nerves-‐III, IV, V, VI, VII, IX, X, XII; taste and smell; visual, ves:bular and auditory systems; cerebellum; basal ganglia; vasculature; cogni:on, learning, memory and language

Ø  IPS case: 9 year old boy who developed Bell’s palsy following an infec9on of a right maxillary molar

Ø  IPS case: 42 year old male presents with leV maxillary quadrant pain and nega9ve clinical exam. Months later, he was found to have a crack in tooth No. 18, with pain referred to the maxillary arch.

Ø  IPS case: 12 year old healthy boy with difficul9es related to an exaggerated gag reflex

Ø  IPS case: 67 year old female experienced ver9go following the extrac9on of a maxillary molar, which had a dilacerated root

Detail of IPS Case Neuroanatomy Module

67 year old female experienced ver9go following the extrac9on of a maxillary molar, which had a dilacerated root. ª  Pa:ent was in a reclined posi5on for the 1.5 hour procedure ª  Extrac:on required use of rota5ng tool, mallet and chisel ª  That evening, the pa:ent felt that the room was spinning.

Episodes of ver5go persisted, promp:ng a visit to the ER where nystagmus was noted. She was diagnosed with benign paroxysmal posi:onal ver:go (BPPV). ² Students answered a series of ques9ons using course resources and at least 3-‐4 ar9cles (original research, review ar9cle, case report). 1.  What is BPPV? 2.  What is nystagmus and how is it related to BPPV? 3.  Describe possible causes of BPPV. What in this pa:ent’s history

made her suscep:ble to BPPV? 4.  How is BPPV diagnosed and what are the current treatments?

www.juniorden:st.com

hEp://www.cmaj.ca/content/169/7/681.full.pdf&embedded=true)

Summary of Student Learning What is benign paroxysmal posi:onal ver:go (BPPV)? ��

What is nystagmus and how is it related to BPPV?

hEps://www.ole.bris.ac.uk/bbcswebdav/ins:tu:on/Faculty%20of%20Medicine%20and%20Den:stry/MB%20ChB/Hippocrates%20Year%203%20Medicine%20and%20Surgery/Neurology%20-‐%20Cranial%20Nerves/page_10.htm


What in this pa:ent’s history made her suscep:ble to BPPV?

ª  Students present cases from the literature suppor:ng a possible connec:on between BPPV and dental surgery. ² Chiarella G, et al. Benign paroxysmal posiZonal verZgo a\er dental surgery. Eur Arch Otorhinolaryngol. 2008 ;265(1):119-‐22.

² D’Ascanio, et al. Benign paroxysmal posiZonal verZgo: An unusual complicaZon of molar teeth extracZon. Br J Oral Maxillofac Surg. 2007; 45(2): 176-‐177.

² Penarrocha M, et al. Benign Paroxysmal PosiZonal VerZgo as a ComplicaZon of Osteotome Expansion of the Maxillary Alveolar Ridge. J Oral Maxillofac Surg. 2001; 59(1): 106-‐107

www.juniorden:st.com

Overview of Anatomical Sciences ✦ Course Faculty

✦ AS-‐I (Fall Semester) ²  Histology ²  Neuroanatomy

✦  AS-‐II (Spring Semester) ²  Embryology ²  Gross Anatomy

AS-‐II Course Content and IPS Cases ✦  Embryology and Gross Anatomy

² Lecture content: embryology of heart, lungs, nervous system, pharyngeal arches and diges:ve system; thorax, heart and lungs, abdominal wall and organs, ANS, fascial layers and compartments, skull, neck, facial muscles, head and neck blood supply, detailed explora:on of CN V, VII,IX, X, XI, XII; TMJ, larynx, pharynx, oral and nasal cavi:es; upper extremity muscles, blood supply and innerva:on

Ø  IPS case: A 62 year old male awai5ng liver transplant who was referred for a pre-‐transplant dental screen

Ø  IPS case: A 55 year old female diagnosed with pneumomedias5num following root canal therapy of a mandibular molar

Ø  IPS case: A 20 year old female received an inferior alveolar nerve (IAN) block for a rou9ne restora9ve procedure on the leV mandibular first molar

Ø  IPS case: A prac9cing den9st experiences 9ngling and numbness in the hand aVer long procedures

Detail of IPS Case Gross Anatomy

A 20 year old female received an inferior alveolar nerve (IAN) block for a rou9ne restora9ve procedure on the leV mandibular first molar.

ª  Several minutes aoer the injec:on, the pa:ent was unable to close leo eye and had generalized weakness of the leo facial muscles.

² Students answer a series of ques9ons using lecture resources and at least 4 journal ar9cles (original research, review ar9cle, case report).

1.  Describe the course of CN-‐VII. Include a descrip:on of the 3-‐D rela:onship of CN-‐VII branches to structures in the paro:d gland.

2.  Describe the current preferred clinical technique for an IAN block, including anatomical landmarks and reference points. (Reinforced in a workshop by the Pre-‐Doctoral Director of Oral Surgery)

3.  Discuss poten:al complica:ons of an IAN block and preventa:ve measures to minimize risk.

4.  Describe this pa:ent’s presenta:on. Explain immediate vs. delayed CN-‐VII palsies and current hypotheses regarding the occurrence.

Summary of Student Learning The pa:ent’s motor findings suggest the anesthe:c agent infiltrated the region of the __________nerve?

Moore KL, Dalley AF. Clinically Oriented Anatomy, 5th ed.

Describe of the 3-‐D rela:onship of structures within the paro:d gland.

Wilson-‐Pauwels L, Cranial Nerves: Func:on & Dysfunc:on

Blanton PL and Jeske AH, Avoiding complications in local anesthesia induction: Anatomical considerations. Am Dent Assoc, Vol 134, No 7, 888-893. 2003

Malamed, S. Handbook of Local Anesthesia, 5th ed.

Inferior alveolar nerve block.

Summary of Student Learning (cont’d) Describe current preferred clinical technique and poten:al

complica:ons of an inferior alveolar nerve block.

Detail of IPS Case Gross Anatomy

As a prac5cing den5st with 4 years of experience, you begin to no5ce numbness and 5ngling in your 4th and 5th digits. You also note difficulty are when puQng on gloves at the end of the day. Massage and rest relieves your symptoms, however, you are concerned with the worsening symptoms and suspect that your work environment needs modifica5on.

²  Students answer a series of ques9ons using lecture resources and at least 4 journal ar9cles (original research, review ar9cle, case report). 1. Review the innerva:on of the muscles of the forearm, wrist and hand

2. Discuss how shoulder and elbow joint posi:on affect the innerva:on and blood supply to the wrist and hand

3. Based on the symptoms, what is the likely diagnosis; use current literature to discuss the incidence of this disorder in dental prac::oners

4. Summarize current literature related to preven:on of this disorder in den:sts

Summary of Student Learning

Review the innerva:on of the muscles of the forearm, wrist and hand ��

What is the likely diagnosis; use current literature to discuss the incidence of this disorder in dental prac::oners

Copyright 2003-‐2004 University of Washington

Median and ulnar neuropathies in US Army dental personnel at Fort Sam Houston, Texas. Shaffer SW, Alexander K, et al. US Army Med Dep J. 2014 Apr-‐Jun:65-‐73.

hEp://www.moveforwardpt.com/SymptomsCondi:onsDetail


Exercise prescrip5ons to prevent musculoskeletal disorders in den5sts. Kumar DK, Rathan N, Mohan S, Begum M, Prasad B, Prasad ER. J Clin Diagn Res. 2014 Jul;8(7) Dental ergonomics to combat musculoskeletal disorders: a review. Gupta A, Ankola AV, Hebbal M. Int J Occup Saf Ergon. 2013;19(4):561-‐71. Review.

Summarize current literature related to preven:on of this disorder in den:sts

hEp://orthoinfo.aaos.org/topic.cfm?topic=a00069 hEps://www.google.com/search?q=dental+ergonomics&biw=1280&bih

Outline

n  Introduction

n  Representative Examples n  Literature Review/Journal Club

§  Dr. Sarita-Reyes




ASYMPTOMATIC SWELLING OF THE TONGUE SINGHAL ET AL., 2014

The following slides are the actual ones designed by the student group (w/ slight edits for today’s presentation). Faculty annotations for today’s presentation indicted in brackets, as below.

[Reference: Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Feb;117(2):159-62.]

H & P •  Age: 10-year old

•  Chief complaint: swelling on left ventrolateral surface of tongue

•  Physical examination: patient was otherwise healthy, oral hygiene was fair

•  Hematologic and urine analysis: Normal

•  Local examination: o  Oval swelling: firm, nontender, freely moveable

§  Size: 1 cm diameter §  Overlying mucosa: yellowish §  Asymptomatic lesion

Clinical Presentation of Lesion

Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Feb;117(2):159-62.

Differential Diagnosis

[Students required to formulate a hierarchy of possible explanations for the clinical presentation; Bloom’s Taxonomy application/analysis or analysis/synthesis?]

•  Reactive lesions

•  Benign neoplasms

•  Malignant neoplasms

•  Infections/Other

Reactive Lesions -Giant Cell fibroma -Focal Fibrous Hyperplasia -Lipoma -Granular Cell Tumor

[Students showed clinical photographs and histology slides. Students added the histology slides on their own, without prompting; Reinforces Histology content taught in preceding semester in Anatomical Sciences I course.]

Benign Neural Neoplasm ●  Nerve sheath tumors

○  Neurofibroma ○  Schwannoma

[Students searched the literature for additional information on these conditions, beyond that discussed in lecture.]

Benign Neural Neoplasm Neurofibroma ●  Affected sites

○  Tongue ○  Buccal mucosa ○  Gingiva ○  Lips

●  Tongue is the most common intraoral site

Benign Neural Neoplasm Schwannoma ●  Uncommon in the oral cavity ●  Tongue is the most common site ●  Usually slow growing

○  Long duration, few symptoms

Leiomyoma ●  Benign smooth muscle tumor

○  Vascular smooth muscle

●  Uncommon in the oral cavity; Affected sites include: ○  Tongue ○  Lips ○  Palate ○  Buccal mucosa

●  Frequently asymptomatic, but can involve: o  Pain, tooth mobility, difficulty in chewing

●  Small, slow-growing, solitary, nodular mass ●  Found in all age groups

○  Mean age of occurrence = 41 years

Benign Salivary Tumor •  Two Categories: -Major and minor salivary gland categories

[This and following slides integrates lecture content in Anatomical Sciences I & II.]

Major Salivary Glands ●  Parotid

○  Largest of Major salivary

●  Submandibular ●  Sublingual

•  Around 800-1000 in submucosa of oral cavity

•  Secretion mainly mucous

Minor Salivary Glands

Benign Salivary Tumor •  Comprise 3% of all

neoplasms •  Most tumors are benign

o  Pleomorphic adenomas §  60% of all benign §  Most common of minor

salivary gland (39%) •  Unlikely in our patient-

usually seen in base of tongue

Atlas of Genetics and Cytogenetics in Oncology and Haematology

Malignant Tumor? •  Unlikely since no pain, is slow growing

and has well-circumscribed margins

www.webpathology.com

[Bloom’s Taxonomy analysis/synthesis or synthesis/evaluation?]

Any Guesses for the Diagnosis? [You will be rewarded….]

[Student spontaneity and creativity; they really got into it.]

Diagnostic techniques

●  Biopsy ●  Stool examination ●  Skull radiography ●  Computer tomography ●  Imaging ●  Fine-needle aspiration cytology ●  Immunodetection

[Student self-generated interest in specific approaches used in Pathology, especially biopsy.]

Diagnosis and management •  Excisional biopsy under

local anesthesia

•  Superficial incision of the overlying mucosa

•  Lesion exposed and nonadherent to adjacent tissue

Diagnosis and management •  Lesion infected with larval

form of T. solium (Cysticercus cellulosae)

•  Cysticercus: fluid-filled sac, surrounded by a fibrous capsule and single invaginated scolex

•  CT scan performed to rule out neurocysticercosis and intracranial calcifications

•  Final diagnosis: Cysticercus cellulosae

Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Feb;117(2):159-62.

Discussion: What actually is Cysticercosis?

[This was new territory for the students, topic not in the pathology syllabus; Nice example of self-directed “ignition” !]

[Student learning about reputable sources; list of reference material provided at end of presentation ]

Cysticercosis (Taenia solium)

•  Larval stage (Cysticercus cellulosae) -pig tissue and muscle

•  Ingestion -poorly prepared food

-autoinfection (egg reflux) •  Egg development: oncospheres

-form within 70 days -“bladder worm” cysts

•  Cystic wall -Single scolex, epithelium-lined

•  CNS: most common location

Symptoms & Complications ●  Generalized symptoms

-Headache, fever, myalgia ●  CNS: most common location

-“Neurocysticercosis” -Intracranial calcifications

●  Seizures, increased ICP meningitis, mental disorders

•  Our pt→ lack of systemic involvement

Oral Sites Affected

Tongue 42.15% *Lips 26.15% Buccal Mucosa 18.9%

*lower lip accounted for 64.7% of infected sites

●  Humans can be reservoirs for T. solium ●  Tongue musculature involvement is rare in humans

Treatment and Prevention •  Surgical excision and biopsy specimen allows

confirmation of diagnosis •  Treatment in other areas dependent on symptoms and

accessibility of lesion to surgical intervention •  Drugs (e.g., praziquantel and albendazole) •  Good hygiene •  Thoroughly cooking meat

“The present case reveals the importance of the histopathologic examination, emphasizing the need to include cysticercosis in the differential diagnosis of oral nodular lesions.”

-- Singhal et al., 2014

Take-home Message

[Desired outcomes for students from this process: Broadening one’s scope of thought; Learning to expect the unexpected; Generating excitement and satisfaction about self- & life-long learning.]

Outline

n  Introduction

n  Representative Examples n  Interactive Q & A

§  Dr. Walsh




Objectives of Pharmacology IPS Sessions

•  Reinforce factual material from lecture •  Raise issues in open-discussion format •  Generate familiarity with sources of

information: texts, FDA, drug labels, journals •  Encourage weighing of evidence to articulate

an opinion •  Demonstrate changes in drug use guidelines

and regulations

Timing, Students, and Instructors

•  IPS scheduling –  In spring semester course, Dental Pharmacology –  In final part of course following relevant lectures

•  About 180 students –  2nd year DMD –  1st year Advanced Standing

•  Two instructors –  Course director paired with lecturer on IPS topic

Rationale for Topics

•  Rationale –  Aspects of therapeutics highly relevant to dentistry –  Areas of controversy with recent changes in

guidelines and regulations •  Topics

–  IPS 1: efficacy and toxicity of acetaminophen OTC and opioid combination products

–  IPS 2: antibiotic prophylaxis in cardiac and orthopedic patients

Sources of Information and Evidence

•  Posted as word document for students prior to the sessions

•  Provides relevant sites with links •  Referred to in the session TurningPoint®

presentation with screen shots

Types of Information Sources •  Pharmacoepidemiologic data •  Product labels: NLM DailyMed •  Drug product information: RxList •  FDA drug information, advisory panel

recommendations, and rulings •  State government initiatives •  Dental literature •  Professional society advisory statements and

clinical practice guidelines

Expectation of Students during Sessions

•  Work in a team of two or three students. •  Access internet resources to seek information for

each question posed in the TurningPoint presentation.

•  Formulate a team consensus, and use ResponseWare to respond to each question with a mobile device.

•  Respond to instructor query regarding evidence for choice of answers and basis for opinions

Design of TurningPoint® Presentation

•  Provide learning objectives, and present a case

•  Ask factual question, and provide answer to reinforce lecture material

•  Pose questions requiring reference to online information sources, and provide evidence from these sources

•  Present opinion question, and encourage debate

Questions Posed in IPS 1: Efficacy and Toxicity of Acetaminophen OTC

and Prescription Combination Products •  How do acetaminophen products compare with respect

to dental analgesic efficacy? •  What are the major toxicities of acetaminophen and

opioids, and about how many deaths occur annually from these drugs?

•  What are recent rulings of the FDA about dosage strength of acetaminophen in prescription combination products and the rationale for these changes?

•  What changes has FDA required in labels, and are they adequate to protect consumers?

•  How do new regulations of MASS Department of Public Health affect prescribing of controlled substances?

Choice of an Analgesic

Patient CR undergoes oral surgery for multiple impacted wisdom teeth. The patient is concerned about potential post-operative pain and requests a prescription for a medication that might be more effective than an OTC acetaminophen product.

What risk would you consider before recommending acetaminophen?

1.  GI ulcers 2.  Hemolytic

anemia 3.  Respiratory

depression 4.  Liver damage 5.  Analgesic

nephropathy

Hepatic Toxicity of Acetaminophen

•  Centrilobular necrosis •  Mediated by CYP450

metabolite •  Risk increased by alcohol

and CYP2E1 inducers •  Risk decreased by N-

acetylcysteine treatment

About how many people die every year in the U.S. from acetaminophen

and its combination products?

1.  40 2.  400 3.  1,000 4.  4,000 5.  10,000

Followed by screen shot from 2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS) showing top 25 classes of drugs causing fatalities and CDC data showing yearly trends

Which is currently included in the label for acetaminophen (APAP)?

1.  Contraindicated in hepatic disease

2.  Do not take with other APAP-containing products

3.  Maximum daily dose not to exceed 4 grams in alcohol abusers

4.  Maximum daily dose not to exceed 8 grams

5.  Avoid opioids due to hepatic risk

What 2009 ruling did the FDA make for acetaminophen labeling?

1.  The maximum daily dose should not exceed 4 gm

2.  The maximum single dose should not exceed 325 mg

3.  Warning must be added of risk of liver injury

4.  Warning must be added to avoid opioids

5.  Warning must be added about gi bleeding

Followed by screen shot of Federal Register 2009 final ruling

Do you consider the current acetaminophen label warnings adequate?

1.  Strongly Agree 2.  Agree 3.  Neutral 4.  Disagree 5.  Strongly

Disagree

Is there evidence of greater analgesic efficacy of an acetaminophen-opioid or acetaminophen-ibuprofen

combination than acetaminophen alone, following third molar extraction?

1.  Yes, more than 100 studies in the last 10 years

2.  Yes, but no studies have been published

3.  No, studies show no difference

4.  Neither is more effective than placebo

5.  Yes, there is published evidence from studies

Moore et al., 2013

Considering the review by Moore JADA 2013, which medica:on every 6 hrs would you prescribe for pa:ent CR if the third molar extrac:on causes moderate to severe pain?

1.  1000 mg APAP 2.  300 mg APAP/5 mg

hydrocodone (Vicodin) 3.  400 mg ibuprofen 4.  500 mg APAP and 400

mg ibuprofen

IPS2: Prophylactic Use of Antibiotics prior to Dental Procedures in Cardiac and Orthopedic Patients

•  What microorganism is the most common cause of infective endocarditis (IE) following a dental procedure?

•  Is bacteremia from a dental procedure preventable by antibiotics?

•  What antibiotic regimen is recommended in patients with high cardiac risk, what is its major toxicity, and how many fatalities occur annually?

•  How do AHA/ADA and NICE (UK) guidelines compare with respect to IE prophylaxis?

•  How did AAOS/ADA 2012 clinical practice guidelines on antibiotic prophylaxis in patients with hip and knee implants change from earlier recommendations?

Antibiotic Prophylaxis?? •  Your 75-year old patient with a history of

alcohol abuse and irregular dental cleanings presents with several fractured molars that require extraction. This patient had coronary bypass surgery five years ago and left hip replacement 6 months ago.

•  Is antibiotic prophylaxis indicated? •  What evidence would support your decision?

Are there randomized controlled trials (RCTs) showing greater efficacy of antibiotics than

placebo in preventing bacteremia following a dental extraction?

1. 2. 3. 4. 5.

0% 0% 0%0%0%

1.  Yes, more than 50 studies in the last 10 years

2.  Yes, there are studies showing efficacy

3.  No, studies show no difference

4.  No, RCTs only show greater efficacy for preventing IE

5.  No, there are only case-control studies

Copyright ©2008 American Heart Association

Lockhart, P. B. et al. Circulation 2008;117:3118-3125

Incidence and duration of bacteremia at 6 time points from IE-related bacterial species

1=zero time, 6=60 min

According to 2007/8 guidelines of ADA/AHA, for which condition is prophylactic antibiotics recommended before a dental procedure?

1. 2. 3. 4. 5.

0% 0% 0%0%0%

1.  Hypertension 2.  Mitral valve prolapse 3.  Prosthetic valve

replaced up to 1 yr prior

4.  Congenital heart defect repaired with prosthetic material up to 6 mo prior

5.  None of the above

Followed by screen shots from publications and summary of recommendations

Considering the 2012 AAOS/ADA Clinical Practice Guidelines, how would you treat your patient who had hip replacement 6 months ago, prior to multiple tooth extractions?

1. 2. 3. 4. 5.

20% 20% 20%20%20%

1.  Describe limits of evidence on antibiotic prophylaxis benefit/risk, so patient can make informed decision.

2.  Use oral antibiotic prophylaxis. 3.  Use topical antibiotics. 4.  Implement oral hygiene. 5.  Consult with orthopedic surgeon.

2012 AAOS/ADA Clinical Practice Guidelines on antibiotic prophylaxis in patients with hip and knee

implants

•  Best evidence does not show antibiotic use reduces hip and knee implant infections

•  Antibiotic use is associated with risks (allergic reactions, bacterial resistance, diarrhea)

•  Routine use is not supported by evidence (but consider in patients at increased risk due to compromised immune system)

•  Decision should be made by patient, dentist and physician; Shared Decision Making Tool developed to facilitate informed consent process

•  Foster active engagement in applying knowledge and seeking new information

•  Reinforce life-long learning skills by emphasizing information sources to guide use of drug therapy

•  Illustrate importance of evidence in decisions about use of drug therapy

Outcomes of Pharmacology IPS Sessions

Outline

n  Introduction


n  Learning Outcomes n  Student Perspective

n  Experiences/Anecdotes n  Course-level Surveys n  Curriculum/Program-level Surveys

n  Faculty Perspective n  Institutional Perspective



Educational Endpoint (reminder: What are we trying to accomplish ?)

Fryer, A. The Integration of the Nurse of the Future Nursing Core Competencies into a Practice Setting, PowerPoint. http://www.mass.edu/mcncps/orientation/m2CompOverview.asp (accessed 12-18-2014)

Competency Framework: Knowledge – Skills - Attitudes (KSA)

Student Perspective


n  Advantages n  Keeps students engaged in material between exams n  Encourages teamwork & promotes understanding of how to lead n  Practice in public speaking & presenting n  Allows students to research material that peaks their interest n  Continually provides dental correlations throughout curriculum n  Variety of course directors’ style of presentation prevents student

fatigue

n  Disadvantages n  Additional work outside of the classroom n  Complicated articles and topics pose obstacles for those

developing a dental and medical lexicon

Course-level Surveys

n  AY 2010-14 n  9 courses w/ data available n  3-5 years of data n  Designed to establish effectiveness of IPS in:

n  Reinforcing lecture concepts n  Enhancing critical thinking & application of EBD n  Integrating biomedical sciences and patient care n  Serving as a useful educational construct


Response range/course= 14%-‐48%





•  Average response rate for course evalua:on surveys across all 9 courses = 52.1% (15-‐100%)

•  AY 2010-‐14; 9 courses, Δ 3-‐5 years data

35%

42%

14%

8%

1%

0%

10%

20%

30%

40%

50%

Very much Somewhat Very liEle Not at all Unsure

Effec5veness of IPS in Reinforcing Concepts Taught in Lecture

~77%

~22%

~ Iden5cal percentages for: •  Enhancing cri:cal thinking & EBD •  Integra:ng biomedical founda:onal

knowledge w/ pa:ent care •  Overall usefulness of IPS in student

learning

Curriculum/Program-level Surveys

n  AY 2014-15 n  Survey instruments recently developed

n  Administered during new-student orientation n  Administered at program ~mid-point

n  Designed to understand students’ view of the factors involved in: n  Self-learning strategies n  Critical thinking n  Active learning


“How do you define Active Learning”? (% Respondents)*

Timing of Evaluation

Discussion w/ others

(e.g. classmates,

faculty, Q&A)

Course-specific

habits (e.g. class

attendance, active

listening, note taking)

Being engaged in &

understanding the material

Combination of theory w/

practical application

(incl. observing

followed by doing)

Use of various educational resources

(done independently

outside of class)

Updating knowledge

Fall 2014¶

(DMD1 & AS1)

35.5 23.6 19.0 16.9 3.3 1.6

Spring 2015§

DMD3 & AS2)

28.1 20.2 21.3 26.9 3.4 0.0

*Qualitative analysis of thematic groupings in open-ended questions on survey ¶ n = 189 respondents (96% response rate) § n = 144 respondents (77% response rate)

Faculty Perspective n  Encourages student self-guided discovery, teamwork &

leadership development n  Fosters interpretation/application of new knowledge n  Encourages development of effective literature searches, critical

thinking & life-long learning n  Promotes faculty interdisciplinary collaboration & curriculum

synergy/“seamlessness” n  Integrates content across biomedical, behavioral & clinical sciences n  Provides a desired small group discussion format within a large

class setting n  Recognition of instructional innovations n  Identifies potential future educators

n  Increases institutional awareness of SoTL ideals n  How students learn ≅ what students learn


Institutional Perspective

n  Facilitates CODA-required predoctoral outcomes n  Institutional effectiveness & ongoing evaluation (Standard 1-2) n  Integration of biomedical, behavioral & clinical sciences (Standard 2-6) n  Critical thinking & problem-solving (Standard 2-9) n  Self assessment and self-directed & lifelong learning (Standard 2-10) n  Application of biomedical sciences (Standard 2-14) n  Ethical decision making (Standard 2-20 ) n  EBD/patient care & critical appraisal of literature (Standard 2-21 & 5-2) n  ? IPE (Standard 2-19)


Parting thoughts…

n  This remains a pleasant work in progress

n  Needs continuing oversight and active support from administration, which we have

n  Outcomes assessment is important (and hard to do well)


Outline

n  Introduction



n  Q & A / Open Discussion (Session Objectives) n  Do methods for active learning (e.g. IPS) promote “learning

by teaching” ?

n  Are such constructs effective tools for the educational continuum ? (faculty-focused teaching ⇔ student-centered learning)

n  In what ways do these unlock students’ potential as both learners and teachers ?

n  Will you share best practices from your home institutions ? Henry M. Goldman School of Dental Medicine

Aud

ienc

e in

put

Thank you !


Documents

IGNITING MINDS THROUGH STUDENT SELF …9582a3b18a6394d0bf2a-2047e15e84f2d475a3bf2d6b165dd80c.r4.cf2.rackcdn…IGNITING MINDS THROUGH STUDENT SELF-DIRECTED GROUP LEARNING: Integrated