curricular adaptations towards problem-based learning in dental education

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Dental Education ISSN 1396-5883

Curricular adaptations towards problem-based learning in dental education

M. Kelly, D. B. Shanley, B. McCartan, M. Toner and C. McCreary Currrculurri Dmelopnrerit Uuit, Dublin Dental Hospttnl, Ltm-oolri Place, Dublrn 2, Ireland

Leader Key words: traditional teaching; self-directed learning; assess- rnent.

0 Munksgaard, 1997 Accepted for publication 1 1 April 1997

HE PHENOMENAL advances in science, technology T and health care which have occurred in recent years make it incumbent on us to re-evaluate undergraduate curricula. The need for change is undis- puted; it is the shape of that change which remains to be identified. Prioritisation of essential knowledge and confirmation of core proficiencies must be em- phasised in every modern dental curriculum.

Decisions on educational strategy should en- compass all three elements of curriculum design: course content and assessment, student conditioning and staff reorientation. Course content in health care professional training such as dentistry should include the development of clinical competence, communication skills, management and analytical skills as well as knowledge acquisition. Assessment, universally accepted as a major motivating factor in student learning, should be appropriate to the course and should measure the capacity of the graduating student to de- liver safe and effective patient care. The student should be enabled to make the transition from the sheltered adolescent product of second level education to the mature, self-directed professional in control of himself and the environment. Staff, the architects of new course design, require time and space to evaluate existing curricula, to explore new developments in education and to become familiar with international trends. Major curricular change can only be justified if its benefits outweigh the disadvantages and inconveniences of planning and implementation.

This paper examines some aspects of the traditional dental / medical curriculum and the indications of the need for change. I t also considers some aspects of new

curricular strategies, especially self-directed interdisciplinary learning (problem-based learning, PBL), and speculates as to how they may affect educational outcomes.

Traditional didactic teaching Traditional teaching is based on the philosophy of em- piricism where acquisition of facts relies on a percep- tual rather than a semantic approach. Education based on this view is strongly focused on transfer of knowledge by continual repetition. It was undoubtedly the method of choice in an era of scarce financial and technical resources where large group teaching enabled transmission of information from an expert teacher to the largest possible audience. Frequently, handouts are supplied to accompany the lecture enabling the average student to avoid the use of textbooks and the li- brary. This approach serves to affirm the dominance of the teachers’ philosophies over those of the students and thus discourages independent thinking and critical analysis through interpersonal discussion. Fragmen- tation, duplication and inflexibility develop as a result of poor communication between university depart- ments. This is especially prominent in basic science subjects and is further compounded by the lack of reference to clinical practice. The integration of knowledge necessary for the development of a holistic approach to dental health care is left to the individual student who frequently forgets or fails to prioritise the information through lack of a contextual framework. Poor long- term retention of information following traditional cur-

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ricula may be one result of this inefficiency of integration (1). Craik et al. (2) in studies on the effect of processing found that subjects remembered the words for which they made semantic judgements much better than those for which they made perceptive judgements.

Traditional clinical training Clinical training in the traditional curriculum in many schools is also gained on a fragmented departmen- talised basis. There frequently is excessive emphasis on examples of secondary and tertiary care and often little regard for patient needs and priorities. Dental and medical educators promote a pathological model of healthcare where intervention is prioritised at the expense of prevention. Insufficient emphasis is placed on communications, personal characteristics and management skills. Conflicting views held by teachers are not used as a source to analyse the logic of the views held; instead they act as barriers to understanding. There has been a general lack of teacher evaluation in traditional curricula.

New curricular strategies The current dental or medical graduate requires the skills of information handling and analysis and en- ablement to continue to assess and to absorb knowledge through the professional postgraduate years. The UK General Dental Council (3) in recent recom- mendations urges that the dentist should maintain the highest standard of patient care by regular partici- pation in education. It forecasts accelerated growth in health informatics and recommends those involved in education to take advantage of these developments. It comments on the report of the Nuffield Foundation (4) concerning auxiliary workers and the dental team and urges that the education of the dental student must include the development of those skills necessary to fulfill the rBle of team leader and guarantor of quality control. In summary, i t states, ”the aim of a dental curriculum is to produce a caring, knowledge- able, competent and skil]ful dentist who is able to accept personal responsibility for the effective and safe care of patients, who appreciates the need for continuing professional development and who is able to util- ise advances in dental knowledge.”

Tedesco (5) stated that dental education is currently being asked:

(a) to increase interdisciplinary integration of curriculum content;

(b) to improve temporal integration for skill acqui-

(c) to strengthen the conceptual correlations between

(d) to promote critical thinking and clinical problem-

(e) to encourage the self assessment of personal per-

(f) to equip for lifelong, self-directed learning.

sition and clinical application;

basic and clinical sciences;

solving;

formance;

Students need exposure to a community health network (3) from the 1st year onwards. They should be involved in primary care clinics, home visits, schools, work places, clubs, homes for the aged. The curriculum should stress the concept of the natural history of disease, incorporating prevention, curative and re- habilitative aspects. Students should participate in the structure, organisation and management of health care systems. The community oriented curriculum should define its objectives clearly, describing the expected behaviour of a competent graduate. These objectives should be made known to both students and faculty from the very beginning (6). The curriculum should include epidemiology both in classroom activi- ties and on field projects.

It is imperative that curricular strategy be adapted to meet the needs of the 21st century.

Gies (7), as far back as 1926, recommended the applied integration of the basic and clinical sciences and the promotion of interdisciplinary critical thinking. The debate about appropriate new curricular strategies has continued unabated. Many educationalists have stated the case for learning based on cognitive activity. This approach is based on rationalism which presumes our knowledge to be primarily the product of our thinking activity. This process involves the development of a theory by deduction based on a limited number of assumptions regarding reality. Green (8) and others suggest that a central function of the mind is to construct models of reality so as to en- able action in the world. The basic idea is that a mental model has a similar relation-structure to the situation that it represents. Problem-based learning is strongly influenced bv cognitive psychology and therefore might be expected to facilitate the development of those capacities required for the practising dentist of the future.

Problem-based learning is not a new concept. Plato and Socrates required students to do the thinking, to retrieve information for themselves, to search for new ideas and to debate them in a scholarly environment. This socratic approach continues to be the basis of learning in the classics in manv universities.

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The problem-based approach was developed in the early 1970s by medical teachers at McMaster Univer- sity in Canada. One of the principal reasons for this development was that, despite the fact that students had acquired substantial amounts of knowledge, they did not appear to be capable of applying this knowledge when required. Barrows (9), one of architects of the McMaster development, was convinced that medical students should build up and anchor their knowledge around clinical problems. He believed that it was the students‘ task to analyse the problems pre- sented by patients and to ascertain the kind of information they needed to resolve them. This would inte- grate the information from various disciplines and knowledge structures would be “problem centred”. It would also help the students to become familiar with the physician’s reasoning process and to learn to identify and to fill gaps in their own knowledge.

Problem-based learning evolved from the case study method practised at the Harvard Law School and the discovery learning approach defined by Brun- er (10). Now there is a network of medical schools throughout the world where problem-based learning and community oriented medical curricula are being developed. Malmo is the dental flagship in this ven- ture. We must learn from their experience and all in dental education are indebted to them for taking their innovative step.

At the School of Dental Science, Trinity College Du- blin, curriculum evaluation and review was initiated more than 10 years ago. At first, multidisciplinary small group clinical teaching was introduced. 5 years ago, further reviews of the curriculum culminated in a decision to adopt a PBL approach. We have been supported in our implementation by many existing PBL schools including the University of Limburg at Maastricht in the Netherlands.

Schmidt (personal communication) in discussing the Maastricht approach described 3 conditions that facilitate learning.

Learning has a restructuring character. Earlier knowledge is used in understanding new information. Retrieval cues reactivate information. The closer the resemblance between the situation in which something is learnt and the situation in which it is to be applied, the better the performance and the easier it is in respect of recall and application. Elaboration of knowledge. Information is better understood, processed and retrieved if students have an opportunity to elaborate on that infor-

mation. Students can elaborate by answering questions about the matter, by taking notes, by teaching peers what they have already learnt themselves, by summarising and by formulating and criticising hypotheses about a given problem. A teaching-dominated approach fails to accom- modate these conditions for learning.

In PBL, problem-solving is promoted as an alterna- tive to the memorising of facts. Clinical reasoning is essential, as opposed to the traditional method of using structured protocols for the care and treatment of patients. The emphasis is entirely on learning as opposed to teaching, and is centred on the students in small groups. The approach is multi-disciplinary and tran- scends departmental boundaries. It promotes the development of team work and social skills. It creates the appropriate context and environment in which to as- similate knowledge and to apply it to the resolution of problems. There is a strong emphasis on the use of group dynamics to facilitate motivation and the elaboration of issues. The problem itself, and its processing by the group, acts as the stimulus which reactivates relevant prior knowledge. During initial discussion of the problem, prior knowledge is elaborated and reinforced by group interactions and by some individual restructuring which may take place as a result. Some of the in- put may not be factually correct. In the formation of a hypothesis, questions will arise which serve as learning objectives and the subsequent learning process is essentially self-directed.

Self directed learning requires of a student (11):

1. 2. 3. 4.

5 .

6.

Recognition of personal learning needs. Desire to correct identified deficiencies. Self-reliance. Capacity to translate learning needs into realistic learning objectives. Ability to identify, evaluate, and make effective use of resources. Ability to assess the efficiency of the learning exer- cise relative to goals.

PBL explores rather than learns.

Issues of knowledge retention There are many convincing arguments made against innovative curricular change especially by academics and scientists who are by training cautious and who consider that the case in favour of change has not been scientifically proven. There are conflicting re- ports on the levels of knowledge achieved in PBL as


opposed to traditional curricula. Verwijnen et al. (12) reported a study from 4 Dutch schools showing no statistically significant difference in knowledge between the traditional curricula and PBL. Woodward et al. (13) found that McMaster graduates appear to be more effective in continuing learning than graduates from other Canadian medical schools. Newble & Clarke (14) found that PBL students demonstrated significantly deeper learning than controls from traditional curricula. DeVries et al. (15) in an intema- tional multi-centre randomised control study of 219 medical students to improve the teaching of pharmacotherapy, concluded that the students from the study group performed sioficantly better than controls. Albanese & Mitchell (16) in a review of PBL outcomes and implementation issues, concluded that caution should be exercised in implementing comprehensive curriculum wide PBL because of the possibility that PBL students may have gaps in their ability to engage in forward reasoning. Objective proof of problem- solving ability is difficult to obtain. Researchers such as Barrows (9) & Berkson (11) expected that PBL students could still be distinguished from others in terms of problem-solving ability but in recent studies admit that such a distinctive ability is unlikely. Schmidt (17) also holds that recent developments in the theory on expertise in medicine assume that expertise is not SO

much a matter of reasoning skills as Barrows (9) expected.

The argument that small group teaching is not cost effective and the view that teaching is an unnecessary intrusion into valuable research time are firmly held. However, experience to date suggests that for student cohorts of fewer than 70, similar resources are required for PBL and traditional teaching, but as num- bers rise, financial considerations may become a bar- rier to change (16). In general, the increased staff/student contact time involves more junior staff while in- volvement in planning groups for senior staff simply replaces lecture preparation time.

Preclinical sciences feel threatened by curricular change and fear a reduction of knowledge in these areas, thereby undermining the scientific basis of medicine and dentistry. Proponents of PBL point to the development of a multidisciplinary approach all through the course, teaching science in context rather than in isolated, indigestible blocks.

Clinical proficiencies Dental education must ensure the gradual acquisition of clinical competence so that the graduating student is competent to carry out dental treatment at least to

the primary care level without harm to patients. The evaluation of clinical competence by proficiency test- ing has been adopted by the EU Advisory Committee on the Training of Dental Practitioners and has been submitted to the Commission as a proposed annexe to the Dental Directives.

Clinical proficiency is not simply a technical ability or a prescribed amount of knowledge; it is a combi- nation of skills, attitude and knowledge which en- ables the clinician to undertake a specific clinical task.

The following is a simple example of one such clinical proficiency based on the ability to remove the buried root of a tooth. If a student is deemed to be clin- ically proficient in the surgical removal of a buried root, this implies much more than the technical or surgical ability required to excise a buried piece of root from the alveolus. It embraces a broad range of knowledge and understanding on which the surgical treatment is based: competence in patient assessment, management, anxiety and pain control, infection control and appropriate operative and post operative care of the local area as well as the whole patient. Implicit in this proficiency is, for example, an appropriate understanding of the processes of wound healing and of factors which might delay or promote healing.

Other examples of clinical proficiencies include: taking a proper case history, including medical and dental aspects, carrying out a thorough oral examination, recognising deviations from normal, diagnosing oral and dental diseases, formulating a long-term treatment plan and carrying out appropriate treatment or referral as appropriate to the needs of the patient. These are but a few examples of the range of clinical proficiencies which are agreed and are currently applied throughout Europe.

Assessment It is difficult to compare success between different systems of education and training using such traditional methods of assessment as essay questions, MCQs, computer-based examination systems and practical examinations. There are too many variables. It is questionable whether any examination system provides useful indicators as to who will be a really effective doctor or dentist. We have come to accept that those who are successful in examinations will also be successful practitioners of their craft, vet there is no scientific basis for traditional examinations as a measure of anything more than an ability to recall information.

The dilemma when examining PBL is that students are at liberty to study what subjects they want and to

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decide the extent to which they should study them, so that in response to any given set of problems, any two students may learn different material. If then the examination is given on the basis of the teachers’ as- sumption of what is learned, some students will be disadvantaged and the examination will become the sole steering influence and remove the impetus from the students. It was because of this that the progress test was designed at Maastricht (18). 4 times a year, all students in the medical school (years 1-6) take the same progress test. It consists of 200-400 questions. A large question bank has been built up covering the broad area of knowledge required for a medical student at graduation. Initially, students may have less than 25% of the information required to answer the questions but this builds up over the medical course to a 70% score on average; a linear progression in their knowledge base. This prevents students from com- partmentalising knowledge, i.e., unless the senior students retain the basic early knowledge, they will not rise through the %s. A second obvious advantage is that each student can monitor his own progress. For each question there is a text reference given and there is a post exam period during which the student is given a computer printout of his or her own corrected exam and can consult the reference and challenge the interpretation of any question. The experience is that on average about 10% of the questions are removed after each examination in response to student challenge. Previous progress tests are taken into account in the final progress test at the end of year 6. However, this is clearly a test of knowledge only.

Many methods are currently used to measure cognitive processes. Objective structured clinical examinations and structured problems are among the most widely used. The transfer-appropriate processing theory of memory states that performance on some memory tests benefits from a prior learning episode, to the extent that the mental operations needed to complete the test overlap with those required during the learning episode (8). It is important that this is taken into account in the design of assessments.

In McMaster (19), there was an attrition rate of about 1% which was thought to be significantly lower than the attrition rate in conventional curricula. There was an 89% positive response from those surveyed in McMaster that they were as well or better prepared for internship than fellow interns. 80% reported that the advantages of the programme outweighed the disadvantages. The annual pass rate has varied from 88 to loo%, an average is about 92% in the Medical Council of Canada’s examination. The McMaster graduates had a significantly higher selection advan-

tage for internships compared to other Canadian graduates. 50% of the graduates have entered primary care, 20% have gone into internal medicine and the remaining 30% are divided among the specialities.

There is little doubt that the assessment or evaluation system being developed in PBL is more relevant to the health sciences than “marathons” of memory recall in traditional examinations. There is a growing body of evidence that, in addition, problem-based learning has qualitative advantages over the traditional approach not least that students find it more enjoyable. The fact that the tutor is also evaluated with the student is a major development. Account- ability will become a requirement of teaching in the future. If teachers do not develop self-evaluation from within, it will be imposed from without.

Conclusion Tedesco’s (20) assertion that we have a great distance to go, in terms of final design for the learning environment is indubitable. Problem-based learning would appear to offer the intellectual solution to many of the shortcomings of traditional curricula in medicine and dentistry. Within the imprecise world of education, there has been a shortage of scientific measurement of outcomes. It is important that all initiatives are care- fully evaluated for their effect on students and staff. New curricula should be designed for adaptability based on measured outcomes. In designing the new 5-year problem-based curriculum at Dublin, we have incorporated a longitudinal evaluation system. It is our belief that further progress should evolve by adaptation on the basis of evaluation and expansion of current concepts rather than by adoption of further untried theories.

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12. Verwijnen M, Van der Vleuten C, Imbos T. A comparison of an innovative medical school with traditional schools; an analysis in the cognitive domain. In: Nooman JM, Schmidt HG, Ezzat ES (eds): ‘Innovation in medical education; an evaluation of its present status’. New York: Springer Pub- lishing Company, 1992 4049.

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17 Norman GR, Schmidt HG. The psychological basis of problem-based learning; a review of the evidence. Academic Medicine 1992: 6 7 557-565

18. Schmidt HG. Educational aspects to problem-based leam- ing. In: Jochems WMG (ed): Aktiverend Onderwijs, Delft: Delfts Universitaire Pers. 1990.

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20 Tedesco LA, Eisner JE, Vullo R, Hollway J. The Buffalo approach to changing the basic science cumculum or toiling and dreaming in the vineyards of dental education. J. Dent. Educ. 1992: 56: 332-340.

Address: M. Kelly Curriculum Development Unit Dublin Dental Hospital Lincoln Place, Dublin 2 Ireland

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