Tag Archives: dental

Standard Operating Requirements

By David W. Chambers

Several years ago I met a man who owns a car wash. When he found out where I work, he told me he had once wanted to be a dentist. In fact, he had been a student at P&S when it was on 14th Street. “I didn’t make it,” he said. “It seemed like all the professors wanted to show you how much they knew. And they didn’t mind telling you how little they thought I knew, and they weren’t very kind about how they did it.”

I told him things have changed. He didn’t seem bitter, just disappointed that he missed out on the transformation that former Deans Dale Redig and Arthur A. Dugoni made at Pacific, in dental education generally and in the profession. Our attitude today is “We’re very glad you are here; let’s develop you into a fantastic practitioner!”

The twin cultural changes go by the names of competency and humanism. The first views education as a learner-centered process for producing a professional ready for practice; the second is grounded in a community that respects the dignity and potential of all its members.

Although these sea changes both started at Pacific and have been nurtured here for more than 40 years, they are now standard operating requirements in every dental school in the United States. That is a bold statement, but one that has teeth. In 1997, the Commission on Dental Accreditation adopted standards saying that, “The stated goals of the dental education program MUST be focused on education outcomes and define the competencies needed for graduation, including the preparation of graduates who possess the knowledge, skills and values to begin the practice of general dentistry [Standard 2-4].“ The American Dental Education Association has adopted, by policy, a generic set of competencies; and all dental schools have developed ones that match their unique missions while honoring the core skills, knowledge and values of dental practice. These are not suggestions; all dental schools must operate this way now or they will lose their accreditation.

In July 2013, a new set of accreditation standards will go into effect, maintaining competency and adding humanism. All dental schools will be expected to maintain a “dental school environment characterized by respectful professional relationships between and among faculty and students … that inculcates respect, tolerance, understanding and concern for others.”

Competency

Competencies were introduced to dentistry in a 1993 Journal of Dental Education paper I wrote, called “Toward a Competency-Based Dental Curriculum.” Since then scholarship in this area has accumulated and other professional programs have adopted competency, including nursing, dietetics, business and optometry.

The process began more than a decade before the first paper when then Dean Dale Redig appointed me as director of the Introduction to Comprehensive Patient Care (ICPC) course. This is the Monday, all-day lecture-preclinical-clinical course during the first four quarters that gets students ready for their fast start in clinical care. It was an unconventional move by Redig to put a non-dentist in charge of the second-largest dental course in the program.

But it was critical for competency-based education. There was no way I could make students in my own image: I had to ask “the customers,” the department chairs and clinic administration, what they expected passing students in ICPC to look like.

The deep roots of competency can be traced to Harvard University’s John Carroll who advocated mastery education. No one should be allowed to move on to the next level until they have mastered the preceding steps. Stanford University’s Lee Cronbach also has his fingerprints on the idea. He was fond of saying that the prevailing approach to education was wrong because it standardized the method and expected a distribution of outcomes. He advocated instead that we fix the outcome and vary the methods.

Dr. Arthur A. Dugoni pushed competency-based dental education farther. In 1990, he appointed me as academic dean and made it clear he expected the competency system to be applied to the whole school. Part of the process was the so-called “big bucket” approach. Virtually all 10-hour lecture courses were combined into larger and more multidisciplinary ones. At the time, the policy of the American Association of Dental Schools (the forerunner of ADEA) was based on complete coverage of all that teachers in various disciplines felt comfortable teaching. This amounted to about four feet of curriculum guidelines and an estimated nine-year predoctoral program. The Curriculum Committee adopted a policy that the educational program would only be justified based on what dentists needed for practice rather than what faculty members wanted to teach.

Pacific’s competencies are posted on our website at www.dental.pacific.edu/x1867.xml. If they read a lot like the job description of a practicing general dentist, that is what they are supposed to be.

Although these sea changes both started at Pacific and have been nurtured here for more than 40 years, they are now standard operating requirements in every dental school in the United States.

Humanism

Humanism is not an educational process like evidence-based dentistry, problem-based learning, technology-assisted education, small-group discussion, vertically-integrated clinics or any other hyphenated methodology. It is a culture. It is who we are. Pacific changed its personality dramatically from the mid-1960s to the mid-1990s. In Dean Redig’s terms, it stopped being a place that tore people down. In Dean Dugoni’s terms, we started to grow people.

When Redig came to Pacific from Iowa in 1969 he found a culture of “toughness.” The College of Physicians and Surgeons was one of the last dental schools to meet the accreditation requirement for integration into a university. There were only a handful of full-time faculty members, and many of the part-time staff were organized into cliques. When William Gies visited P&S to prepare for his now famous Carnegie Foundation report: Dental Education in the United States and Canada, he characterized the school as having a “survivor mentality.” No eyebrows were raised when faculty members berated students in front of their patients. Unsatisfactory lab projects were destroyed on the spot as a kind of public entertainment. Students were dismissed in the middle of a term on nothing more than the suggestion to the dean from a department chair.

All deans until Redig had been insiders (one actually owned the school). The University wanted a change more than the faculty did. But it was obvious that the school’s conditional accreditation status could only be removed by curing the culture. Redig’s response was swift and structural. There were a few meetings, clear guidelines articulated, followed by a period of several months to see who would blink first. New faculty members were brought in to replace those who left. Part-time faculty members were required to take salaries so they could not remain a “fifth column”, and the number of faculty members was increased. Within a few years, a new foundation had been laid by professionalizing the faculty.

Redig had found students somewhat reluctant at first to become beneficiaries of humanism—and also wary of the possibility of getting caught in the middle of the tension between the dean and the faculty, of which they were clearly aware. There were other risks; the old system was more certain: survivors prospered. However, when they fully realized that Redig had meant what he said, and followed through with implementation of new rules and a new way of student, faculty and staff life in the school, they became strong supporters of the positive direction and change that had been put in place.

The second phase in converting Pacific’s culture to humanism was much more gradual and systemic. Dugoni was a product of and understood the old ways at P&S, but he was not sympathetic to its demeaning tendencies. In fact, at one point in his early, part-time teaching career, he had been threatened with immediate firing over his grading practices.

Dugoni focused on the student dimension of humanism. He made students partners in bringing about the humanistic culture. He met with students constantly, in small groups, several-hour meetings that demonstrated his willingness to listen and thus communicate respect, regardless of the details of the conversations. He learned student’s names, and the names of their patients and their children. He was saying, trust first, and then we can do business. It just made sense to Dugoni that students have a unique perspective on their situation and would accept responsibility for their education. The regular evening meetings between student and faculty leaders were notorious for Dugoni’s insisting that the dedicated and most concerned people regarding improving dental education at Pacific were in the room. If they could not make things better no one could.

Dugoni implemented formal changes designed to foster humanism as well. He directed me to lead all department chair searches, about 10 in all, and to oversee the hiring of all full-time faculty members. It was no accident that a criterion in every such search was “understands and respects the unique humanistic culture of Pacific.” That was often the deciding factor in who was hired and who was not. Dugoni also asked me whether anything could be done about student promotion standards. The old system, still used at some schools, involved dismissing students simply based on a low GPA. The new one began there but probed into why performance was below expectation and whether anything could be done to correct it. Contracts were written for students in trouble, requiring tutoring, counseling, diagnostic testing and retesting. Only when attempted remediation failed, or in a few cases, when students declined participation, would students be dismissed or asked to repeat a year.

Both Redig and Dugoni were fond of observing that the way students are treated in dental school shapes the way they will treat their patients, their office team and even their family once they graduate. Between 1995 and 2006, 176 practicing dentists had their licenses disciplined in California. Not one of them was a Pacific graduate.

We were fortunate in the selection and the order of our two previous deans. Redig’s decisive structural changes were needed to pave the way for Dugoni’s more gradual personal touch. The changes they created at Pacific made us all better and are now imitated by every other United States dental school.

I like to think that the fellow who runs the car wash was just the unfortunate victim of bad timing. If his likes were to come into Pacific today there is every reason to believe he would graduate a competent practitioner with a deep sense of worth and dignity.

Sea Change: New Small-Group Approach Planned for Main Clinic Mirrors Private Practice Model

By Dan Soine

A sea change is coming to the sea of chairs spanning the Main Clinic at the Arthur A. Dugoni School of Dentistry.

The physical expanse of the operatories looks impressive. New patients, visitors, students and others who visit the Main Clinic for the first time have a nearly unanimous reaction to its sheer size – it sure doesn’t look like any dental clinic they’ve ever seen.

But now the clinic is preparing for a major transformation. While the full expanse of Main Clinic operatories will remain in place, much of the organizational and behind-the-scenes structure of the clinic is changing in the next year.

Ultimately, these updates will ensure that the school continues its legacy of providing an outstanding, clinically based education to students, and comprehensive, patient-centered care to Bay Area residents in need.

“Creating clinically trained dental professionals is at the very heart of our school’s mission,” explains Dr. Richard Fredekind, associate dean for clinical services. “The new changes will keep us at the forefront of dental education and ensure that the clinical experience we provide remains second to none. Our clinics were good before, but with these updates, they’ll only get better.”

The most fundamental shift to come is a reorganization of the Main Clinic from four group practices into eight student private practices, each with its own practice leader (formerly known as group practice administrators or GPAs). The reduction in the average size of each practice will allow practice leaders to work even more closely with students than before.

Other changes are coming as well. The second- and third-year classes will be merged in the clinics. There will no longer be a separate second-year clinic or “second-year experience.” Students now will have two years of clinical practice at their individual learning paces, achieving competency in the various disciplines managed by their student practice leaders, and faculty within the practices.

In addition, first-year students will have an opportunity to gain additional exposure to the clinic. From the start of their first week, first-year students will get introduced to their student private practice and forge an even closer relationship with their practice leaders. They won’t be treating patients directly at this point, but will spend additional time getting familiar with the people, processes and procedures involved in patient care.

The changes to the clinics are the results of a planning process that started several years ago as part of the implementation of the school’s strategic plan, Advancing Greatness. More than 50 people were involved in two task forces to analyze how the Main Clinic can continue to refine and enhance its structure and processes to the benefit of patient care and student education.

A Model Adjustment

What’s driving these changes?

In 2008, the Dugoni School of Dentistry made a major philosophical and practical change to the way it educates its students through the development of the Pacific Dental Helix Curriculum. This new approach places a strong focus on active learning and critical thinking by integrating multiple disciplinary areas. The goal is to move toward small-group, case-based learning as a signature pedagogy. The process of developing the new curriculum also called for a complete review of the clinical practice model to make sure that this important component of the school’s educational program was staying on the leading edge of dental education.

“A major component of the development of the clinical practice strand of the Pacific Dental Helix Curriculum is to serve as the practical laboratory to integrate the practice management curriculum into the student private practices,” said Dr. Nader Nadershahi, executive associate dean and associate dean for academic affairs. “Students are not only learning to manage the diagnosis and delivery of care, but also the management skills to develop and maintain a productive practice.”

In early 2009, a task force was created to look at the existing clinical teaching model and make recommendations on the organization and management of the system. As part of its background work, the task force performed a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of the clinic system. The group also discussed issues such as faculty coverage, student and faculty attendance, and differences in teaching between the second- and third-year clinics. A separate task force reviewed the resulting recommendations (See Master Plan sidebar) and developed an implementation plan.

The task force teams identified strengths in the current clinic teaching system that the new model retains or improves upon. These current strengths include excellent clinical training; a humanistic approach to education; comprehensive patient-centered care; the school’s generalist model and the use of specialists for difficult cases as in private practice.

Educational and Operational Benefits

The new clinical model is designed to be truly patient centered, stressing the “ownership” of the patient’s care by all treating and supervising team members. The new model will provide some flexibility in teaching and allow all members to capitalize on their personal strengths. It will also tie into the Helix Curriculum through the integration of clinical, biomedical, and behavioral sciences, and ensure careful supervision of patient care, with meticulous safety precautions during all clinical procedures. In addition, the new model will better ensure adequate patient distribution among students.

Delivery of services will also be adjusted. The services offered in the comprehensive care setting will be expanded to include simple procedures in the disciplines of endodontics, oral surgery, periodontics, removable prosthodontics, implants and orthodontics, which will decrease the number of referrals outside of the Main Clinic to other specialists in the school. This change will ensure continuity of care for the patients and also better reflects what happens in private dental practices. Furthermore, it will increase the value of the specialists, which in the new model will supervise only more complex procedures, where their expertise can be best utilized.

The new clinical model is designed to be truly patient centered, stressing the “ownership” of the patient’s care by all treating and supervising team members.

Under the new model, the screening and emergency care rotation will be absorbed into the normal student workload. This will allow students to treat and follow up with their own emergency patients. As in private practice, emergency patients will be seen when time allows. This means that students who have cancellations or “no show” patients can still have learning experiences. Patients will be screened by teams, which will allow faculty to assign new patients as needed within the team.

Another key benefit of the reorganized clinic model is the strengthening of team spirit, thanks to the inclusion of a strong leader who organizes huddles and monitors each team. A more hands-on approach will increase knowledge about individual students and allow for small problems to be handled before they grow to impact learning and patient care.

Another change will involve patient scheduling. Rather than having students schedule appointments on their own, the school is moving toward staff-managed and technology-assisted appointments. Lightweight laptops will be available for staff to use chairside to make next appointments for patients. Plus, touchscreen monitors have already been installed in the patient reception lobby for use by patients to check in. The electronic check in will be a more convenient and quicker way for patients to check into the clinic, compared to waiting in line at the lobby reception desk.

All of these operational changes are expected to increase chair utilization and decrease complaints from patients about not being seen by their own student dentists. The shift to smaller and more collaborative teams is also expected to lead to a decrease in waiting times for students looking for supervision by faculty. Thanks to these changes, the school expects clinic productivity to increase by 10%.

A Commitment to Delivering the New Model

The changes in the clinic model, and the resulting new policies and protocol, will require significant cross-training among faculty, staff and students.

“Everyone is interested in how the changes will impact them,” said Fredekind.  “We’re keeping the lines of communication open with students, faculty and staff as we move forward. We’re open to feedback and want to make sure that the overall implementation will ultimately enhance the experience of both students and patients.”

The dental school expects to fully implement the new clinic model by July 2012, with minor adjustments as needed subsequently. However, while the clinic will run differently, the changes do not mean an immediate end to the sea of chairs in the clinic. The switch to the new model will not be complete until after the school takes occupancy of new facilities in the future. Then, it will more adequately have physical space that allows for the new distribution of eight teams with physically separate clinic spaces.

While the school incorporates the new model within its existing facilities, there may be some bumps along the way. A sea change does not guarantee smooth sailing! However, the faculty, staff, students and administration are committed to this clinic transformation and excited about what the future holds for education and patient care at the school.

Dan Soine is Director of Marketing & Communications at the Dugoni School of Dentistry.

It’s A Small World After All: Dugoni School Initiatives Go Global

By Eric K. Curtis, DDS, MA

For some time now, the planet’s skin has been tightening. It’s as if the whole earth has been trying to merge and integrate, even coalesce, at least in terms of connectivity and commerce. The telephone made the world accessible. Television made the world familiar. Jet propulsion made the world small. The personal computer made the world—as journalist Thomas Friedman famously phrased it—flat. These days, the world is more open and competitive than ever before, and on its newly level, equal-opportunity playing field the Arthur A. Dugoni School of Dentistry lately has been busy exercising, reaching out in fresh, exciting directions. The world is reaching back. Welcome to Pacific’s world of global initiatives in dental education.

The dental school has a long history of promoting international relationships. When I graduated in 1985, faculty members Walter Hall and Don Strub encouraged me to apply for a position at the dental polyclinic of the Centre Hospitalier Universitaire Vaudois in Lausanne, Switzerland, where I would follow a string of Pacific grads, including Drs. Woody Isch ’84, Bill Dorfman ’83, Karin Hansen ’83 and Paul Griffith ’82, into the pale green corridors of the Service Odonto-stomatologique. In 1987 the school brought its cross-cultural proclivities home when it inaugurated the International Dental Studies (IDS) program, enabling foreign-trained dentists to earn a DDS degree in the U.S. The Dugoni School of Dentistry’s international orientation went from program to policy with the development of its 2007 Strategic Plan, which identified as a key directional goal “to become an international leader in educational innovation and professional development.”

Yet even in their nascent stages, Dugoni School of Dentistry’s international initiatives have already yielded significant fruit. “We’re interested in these relationships because both sides grow,” says Nadershahi.

A clutch of congruent interests moved the school to that intercontinental tipping point. Pacific’s main campus in Stockton, launching its own University-wide international initiative, the Global Project of Professional Development, supported the dental school taking a central role in world outreach projects. The dental school’s strategic planning committees realized that transborder connections would neatly serve all seven of the school’s declared core values—humanism, innovation, leadership, reflection, stewardship, collaboration and philanthropy. Dean Patrick J. Ferrillo, Jr. brought with him a strong interest in the international cross-pollination of ideas. (In 2009, for instance, Ferrillo gave a presentation in Rio de Janeiro, “Leading Global Change in Undergraduate and Postgraduate Cariology Education,” at a conference initiating an ambitious 10-year enterprise called the Global Caries Initiative.) And a new generation of dental students, eager to make improvements in the world, was itching to organize trips to developing countries, and students in fact were already making them on their own to places like Guatemala, Peru and the Philippines. “The world has flattened,” says Ferrillo, “and we have the kind of motivated, far-seeing people at the Dugoni School of Dentistry who feel an obligation to share and then go out looking for opportunities. They continuously want to do more.”

As a result, the dental school is now engaged in a number of collaborative educational projects around the world, from the Pacific Rim to the Middle East. One strong sign of the dental school’s commitment was its agreement in 2009 to house the International Federation of Dental Educators and Associations (IFDEA), a 15-year-old organization of several hundred dental schools worldwide previously operated through the American Dental Education Association (ADEA). Ferrillo, who is currently IFDEA president, named Dr. Anders Nattestad, professor of oral and maxillofacial surgery and director of global initiatives at the dental school, as IFDEA executive director. IFDEA’s presence at Pacific also helps facilitate school-sponsored leadership programs for international faculty and administrators. Dental school representatives, including Drs. Ferrillo and Nattestad, Executive Associate Dean Nader Nadershahi ’94, IFDEA vice president, and Foundation Board Member and past Alumni Association President Colin Wong, traveled to China in 2009 to sign a collaborative agreement to develop student and faculty exchanges with the School and Hospital of Stomatology at Wenzhou Medical College, which had already previously sent representatives to the Dugoni School of Dentistry several times. Their visit to China also included meetings and lectures at the Guanghua School Stomatology at Sun Yat-sen University in Guangzhou.

The strategic planning process itself made the dental school’s international inclusivity easy to envision.
Dr. Karl Haden, founder and president of the Academy for Academic Leadership in Atlanta, the strategic plan’s facilitator, also teaches leadership development courses to the dental school faculty that educators from other U.S. institutions also attend. “We have already been including faculty from other schools,” notes Nattestad. “It was natural for us to say, ‘Why don’t we expand?’”

Expansion, indeed. While it regularly welcomes visiting international educators, the Dugoni School of Dentistry recently contracted with the University of Kuwait to provide a much more comprehensive service—a five-year faculty training program. Nadershahi points out that the program will not be the prelude to a brain drain. “We want to develop their graduates to return and become leaders in their own educational institution,” he explains. Young Kuwaiti dental faculty members—one has currently begun and another is scheduled to begin in summer 2011, while a third has gone through the graduate orthodontics program—will spend two years in the AEGD program to learn how our graduates deliver dental care, absorbing not only techniques and materials but also American dental culture and attitudes toward high standards of care. Program participants will then undergo two years of graduate work in education in conjunction with Pacific’s Benerd School of Education, and one year more in practicum teaching back at the dental school, where they will practice managing educational programs.

While the dental school has fostered relationships with schools in China, Japan, Kuwait and Thailand, among others—in 2010 Nadershahi reported to the Alumni Association that 13 initiatives have been started with other dental schools around the world—one of its most shining examples of a sustained, multi-factorial alliance is in Egypt. In 2003 Dr. Enaya Shararah, professor at the University of Alexandria Faculty of Dentistry in Eygpt, was traveling in California and contacted Dr. Eugene LaBarre of Pacific’s Department of Removable Prosthodontics. LaBarre, who had been to Egypt several times with his college rowing team in a show of Cold War-era “ping pong diplomacy,” was willing to talk. Over the course of several visits, Shararah, who hoped to foster a connection with a U.S. dental school to help improve dental education in the Middle East, took a great liking to the faculty and teaching methods at the Dugoni School of Dentistry. She subsequently invited LaBarre to an Egyptian dental conference, during which she took him on a tour of a half-dozen local dental schools. By 2006, Shararah had become affiliated with a new private dental college, Pharos University Faculty of Dentistry, which was deeply interested in getting Pacific’s input.

Dental school participants were careful to respect their hosts’ sensitivities, but the Pharos faculty was eager to learn. “They recognized that they had profound needs in curriculum and faculty development, in recognizing and teaching high standards,” LaBarre says. “We realized that improvements that start in the school will ripple out into society in the form of better dental care.” LaBarre visited Pharos University Faculty of Dentistry with Nadershahi and Dr. Terry Hoover, vice chair of the Department of Dental Practice. The Dugoni School of Dentistry drew up an agreement to cooperate with the new Egyptian school, offering advice, support and curriculum development materials; exchanging faculty and students; and eventually developing joint research projects.

In 2009 two groups of dental faculty and students from Pharos University completed two-week summer visits to San Francisco, where they participated in classes and labs at the Dugoni School of Dentistry. The Egyptian students attended specially designed seminars—in which they studied the management of such problems as pit and fissure defects and when to extract third molars in young adults—culminating in presentation of case reports and treatment plans in front of Dugoni students. Ferrillo observes that all parties benefit from this kind of exchange of people and information. “Their faculty and students learn our integrated curriculum and our humanistic model of education, which is nonexistent in the rest of the world,” he says. LaBarre thinks the process itself is instructive. “This is training for us,” he says, “in how to interact and cooperate with a developing institution in the developing world.” And now, Shararah is also an adjunct professor in the Department of Removable Prosthodontics at the Dugoni School of Dentistry.

Another expression of the dental school’s international spirit is its formalization of student mission trips to developing countries like Fiji. Nattestad and Eve Cuny, director of environmental health and safety, are working out issues of insurance, travel safety, local government cooperation and allocation and transportation of instruments, supplies and equipment to transform such trips, previously organized outside the school’s auspices by the students themselves, into official Dugoni School of Dentistry delegations. His ambitions for such student ventures are much higher than simply organizing a few happy days of extracting teeth. “We would like to avoid ‘hit-and-run dentistry’ that doesn’t sustain itself,” Nattestad says. “We will try to build local centers for care and patient education—along with alliances with other U.S. schools to help support them—that will last after we go home.”

Many elements of the dental school’s strategic plan, of course, are still only beginning. Yet even in their nascent stages, Dugoni School of Dentistry’s international initiatives have already yielded significant fruit. “We’re interested in these relationships because both sides grow,” says Nadershahi. “They have to be beneficial not only to those we collaborate with, but to our faculty and students as well, to broaden their outlook and cross-cultural competency.” One reward is perspective, which demands an open mind and even a healthy dose of humility. “We can protect the strength of our education and delivery models by comparing and collaborating,” Nadershahi says.
“We can’t just close our eyes and assume we’re doing everything right.”

While he is quick to characterize current progress as modest, LaBarre expresses a deep satisfaction with his international work. “The whole experience,” he says, “including changes in the thinking process itself—for us, as well as them—is rich beyond what I can describe. I have a lot of pride that we have done something very positive.”

Nadershahi likewise sees great potential for good in the school’s increasingly international bent. “Our goal is to raise the bar for education,” he says, “which leads to improved teaching, which raises the level of care, which ultimately improves access to care. This is an important legacy we can leave for the future of oral health.”

Dr. Eric K. Curtis ’85 of Stafford, Arizona, is a regular contributor to Contact Point and is the author of A Century of Smiles, a book covering the dental school’s first 100 years.