VIGNETTE

The patient care delivery environment

Student to the Dean: “Sometimes the faculty just chew me out in front of the patient telling me what I did wrong. It’s embarrassing and I wonder what the patients might think. I feel incompetent and my patient must feel like a guinea pig.”

All dentists first practice as students and model behaviors that they observe in the clinical practicum. The means of educating dentists in clinical procedures is unique. For most dental students, nearly all clinical care they witness in dental school is delivered by them in their own clinical education, for example, the clinical practicum. No similar type of clinical experience exists in any other type of health care education. Dental educators are in a parental role as students sequentially take on the knowledge, skills, and behaviors of dental practice. They do so in a clinical delivery environment created solely for their clinical education. Thus, the first experiences often guide future experiences.

As one who taught skiing, I observed two instructors, Klaus, the ski school director, and Linda who worked almost entirely with children and disabled skiers.

Klaus: “No you are doing it all wrong! He scowled to the class and called out to the children in his ski class. Fear enveloped a student as he tried to follow a long list of quickly stated verbal instructions and fell on the first turn.

Linda: Today, we are going to have fun. You kids are ready. You did so well the last lesson, I know you will do great. The sun is shining. The snow is perfect and everyone is going to learn something today that they are going to love.”

Ask yourselves which students are going to enjoy skiing and which will fear it. Those who fear it often become the “speed demons” racing from top to bottom at full speed with no turns and a good measure of bravado to suppress their fear. They ski past the happy former students of Linda who with Zen like pleasure carve turns and enjoy the terrain beneath their feet.

It is the same in dentistry. Those who fear a procedure take shortcuts and are unable to be self-critical lest they feel as though they are playing the role of the critical instructor, this time chewing themselves out, mercilessly. Instead they often become “speed demons,” bombing through the clinic day without any helpful self-appraisal or true enjoyment or appreciation for the tasks at hand or their meaning. Patients become a sideshow to the inner demons brought on by the dentists own sense of inadequacy. This obviously compromises the ethical construct of their dental practice, obviates continual improvement, and creates a self-hating dentist.

Solutions

In the above dental school vignette, it is clear that the faculty member is also frustrated and unhappy. The faculty member does not feel in control of the clinical situation and feels their only avenue toward minimally adequate completion of the procedure is with bitter cajoling. Admittedly, the clinical dental education environment is a challenge (as it is with a class of beginner skiers), but the current environment on many dental school clinic floors creates an unacceptable environment for promoting ethical practice.

Dental clinical educators have but one person to “chew out “for inadequate care, it is their collective selves. The construct of the clinical practicum does not ensure direct and continuous responsibility and vesting of faculty for the highest level of care for the patient. In an environment where the faculty see themselves as the patient’s dentist, they would be applying ethical standards of quality beyond how they see themselves on the clinic floor.

The distribution of responsibility for patient care across components of treatment and across time is one component of this flawed clinical construct, and the second is establishing who is responsible for clinical care across discipline, and time. Faculty are often supervising procedures they did not treatment plan and would have performed by different means or in different ways. Each visit might include a different faculty member.

Patients in the community have a general dentist who comprehensively cares for their patients and makes decisions about when their patient might benefit from other providers. In the dental clinical practicum, a primary care dentist who is involved continuously and responsible for care across time and student’s years would address this problem well. In some schools they are called team leaders, whereas in others, they are referred to as practitioner or as compared to student centered care, dentist centered patient care.

VIGNETTE

The ethical burden of clinical requirements

A group of students are sitting in the library. Each has out their patient care experiences, their current comprehensive patient group, and list of requirements. One stated, “There is no way I can graduate with these patients. None of them need fixed or an RPD. I need to dump them and get new ones.” Negotiations and bartering for patients then ensued.

Students are driven to objectify their patients and to see them as a set of procedures rather than a person with diseases such as caries, periodontal disease, and edentulism among others, that they are working with to improve their health. The requirement-driven curriculum is also divided into extreme subsets of procedures that drive treatment decisions. Thus, if a patient could have a composite or a crown for a lesion, but one is needed over the other as a requirement, that can drive the treatment decision rather than what is medically best and most economical based upon evidence-based practice. The practice of dentistry is then built around the procedures and not about the health status of patients treated for a disease. This results in a procedure-based dental practice. For example, the American Dental Association (ADA) coding resisted diagnostic codes and presents a plethora of codes for nearly identical procedures. Dentists are not seen as providers of health evaluation and management (E & M) services and only recently developed codes for this, which focus on clinical examination, not history or patient counseling or other standard E & M components of medical practice. In the requirements-based environment, the dentist is seen as one who does procedures and not as one who improves health.

Solution

Dental school clinical practicum requirements need to be put into broad strokes such as experience with direct restoration, experience with indirect restorations, periodontal care, oral surgery, orthodontics, pediatric dentistry, special care dentistry, and public health dentistry. The measure of performance in the clinical environment needs to be in the improvement of health. For example, were caries controlled? Did periodontal status improve? Did patient change oral health behaviors? Did patient gain access to care and continue to undergo treatment? With regard to psychomotor skills of practice these remain essential for good dental practice, but need to be seen more globally such as in the ability to utilize instrumentation and technique properly rather than the endless step-by-step checking that currently occurs on the clinic floor.

VIGNETTE

The ability to pay drives the treatment plan

Faculty member at a meeting on improving clinic operations: “What we need to do is get these deadbeats out of our clinics. They can’t afford our treatment plans and they are taking up space.”

Students are in a vacuum when trying to navigate systems-based practice in oral health care. Although there are about 50 million Americans without health insurance, over triple that number are without dental insurance. When they are in practice, they will quickly learn that nearly all the oral health care that is needed will have to be paid for out of pocket or will not be delivered. Each dentist in America is responsible for about 2000 lives (150,000 dentists for about 300,000,000) but the typical dentist does not even carry half as many patients on their roles. Dental schools do very little to teach or inspire students as to how to reach and improve the care of the majority of Americans who cannot afford the services they were taught to do.