Milieu in Dental School and Practice
Dental Clinical Teaching: Perceptions of Students and Teachers Tania M. Gerzina, Ph.D.; Tim McLean, B.D.S.; Jo Fairley, B.A. (Hons) Abstract: The objective of this study was to explore perceptions of dental student clinicians and clinical teachers about dental clinical teaching to provide primary data for dental researchers and educators. Student focus group data provided background for development of a questionnaire that explored three themes related to clinical teaching. Twenty-one teachers and forty-five student respondents completed the twenty-five-item questionnaire in 2003. In the theme of the teacher/student relationship, no statistically significant differences were seen between teacher and student group perceptions. In the theme of educational theory applied in dental clinical teaching, a statistically significant difference was seen between teacher and student groups in the value of preclinical instruction in senior clinical years and in the value of a clinical log book. In the theme of skills required for clinical dental practice, a statistically significant difference was seen between teacher and student groups in the value of a critical appreciation of evidence-based practice as one of the skills. The study overall indicates that the dental clinical learning environment supports close perceptual conformity between students and clinical teachers in regard to what each group considers to be “good practice” in clinical teaching. The findings of this study indicate that some techniques that have been advocated to enhance clinical learning, such as evidence-based teaching methods, require further investigation. Dr. Gerzina is a Senior Lecturer in the Faculty of Dentistry, University of Sydney, Sydney, Australia; Dr. McLean is a general dental practitioner, Sydney NSW, Australia; and Ms. Fairley is Assessment and Administration Officer, Faculty of Dentistry, University of Sydney, Sydney, Australia. Direct correspondence and requests for reprints to Dr. T.M. Gerzina, Faculty of Dentistry, University of Sydney, 2 Chalmers Street NSW 2010, Sydney, NSW, Australia; 612-92115912 fax;
[email protected]. This project was supported by a grant from the Australian Dental Research Fund. Key words: dental clinical teaching, student/clinical teacher relationship, clinical supervision, professional skills Submitted for publication 4/8/05; accepted 8/23/05
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n regard to dental education, it has been suggested that “the clinic is the learning environment to which all our students aspire,”1 requiring the “transfer of knowledge from the basic sciences to the clinic by tuning and restructuring of knowledge.”2 How learning and teaching best occur in this environment for the preparation of dental students to advance to independently provide patient clinical care is an important central business of dental educators and clinical supervisors alike. The learning environment of the clinic or hospital is a challenging area for both teacher and student. In this setting, the student is a trainee clinician responsible for patient care, and the clinic is both a patient care facility and a learning environment. In clinic, students are expected to demonstrate diverse competencies simultaneously, including a range of skills, broad knowledge base, professionalism, and empathic ethical behavior. Recent reports in dental education point to the value of the early introduction of students to the clinical environment, largely be-
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Journal of Dental Education
cause of the demonstrated value of contextual learning and the facilitation of integration of knowledge from basic to clinical sciences.1 Clinical teaching typically involves the supervision of a trainee clinician by an experienced clinician, and as a consequence, clinical education usually involves a range of teaching modes. Clinical supervision may be defined as the “provision of monitoring, guidance, and feedback on matters of personal, professional, and educational development in the context of patient care.”3 The student/clinical teacher relationship has also been suggested to mirror the therapeutic alliance that exists between patient and physician because it represents an educational alliance.4 Clinical teaching in medical education has been extensively examined.5 Effective medical clinical teachers are considered to be those who have empathy, are capable of providing support, exhibit flexibility, and have the ability to gauge student development, in addition to being interpretive, focused, and practical.3 Effective supervision of learners in-
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volves problem-solving by students and instructors together, along with feedback, reassurance, and theory-practice linking.6 There is preliminary evidence that effective clinical teaching in medicine may have a positive impact on patient outcomes. For example, Fallon et al. found that patient outcomes improved when direct supervision of the student clinician is combined with focused feedback.7 In a dental education context, clinical teaching has been less extensively examined, for example, by O’Connor et al.8 Effective clinical instruction in dentistry is associated with meeting teaching responsibilities, behavior conducive to clinical learning, technical competence, and work enjoyment.7,9 The ability to motivate students, explain difficult concepts, display interest in the subject, show compassion and caring, and be proactive was also highly rated by students in a study reported by Chambers et al.10 Clinical teaching in dental programs is supported by a range of educational modalities supporting patient care such as large group (e.g., lectures), small group (e.g., tutorials), collaborative (e.g., PBL), clinical case-based, interactive (e.g., role play), simulation, and computer-assisted modalities. The perceived value of these modalities to clinical teaching and learning in dentistry can be considered in the light of making efficient use of teaching resources, being able to objectify clinical sessions, facilitating development of professional attributes, sharing common clinical concerns, and affording a degree of individual student interaction.10 This study presents the findings of an investigation of clinical teaching in an Australian dental school. A survey was used to elicit the perceptions of the central partners in that environment—namely, the students and the teachers. The study was implemented to test the hypothesis that these two groups have different views of the value of teaching methods to prepare students for independent clinical practice.
Methods Two student focus groups were conducted in 2003 during a teaching semester to provide background for development of the questionnaire. The focus group discussions explored student ideas and perceptions about clinical teaching in dentistry. Volunteers for each of the two focus groups came from students enrolled in the new curriculum for the Bachelor of Dentistry (B.Dent.) program and from students enrolled in the older curriculum for the Bach-
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elor of Dental Surgery (B.D.S.) program at the Faculty of Dentistry, University of Sydney. These programs are described in detail elsewhere.11,12 Briefly, the B.D.S. program was a five-year, discipline-based program featuring a range of teaching styles such as lectures, seminars, and case-based learning. The B.Dent. program, which commenced in 2001, is a four-year competency-based program using problembased learning (PBL) throughout the program. Clinical teaching styles used in both B.D.S. and B.Dent. programs are similar; dental clinician teachers provide close supervision of students in both. One focus group consisted of four B.D.S. students; the other focus group consisted of four B.Dent. students. Each focus group discussion was one to three hours in length. This number of participants, which allowed discussion to proceed efficiently, reflects recommendations for composition of participatory focus groups.13 The focus group participants identified several aspects of clinical teaching that were united into three themes and that together were structured into a set of questionnaire statements used for data collection. These three themes were 1) the teacher/student relationship, 2) educational theory applied to dental clinical teaching, and 3) skills important for dental clinical practice. An example of a questionnaire item in the theme of “educational theory applied to dental clinical teaching” was the following: “small group teaching, such as tutorials, are valuable to the development of dental clinical skills.” Questionnaire statements grouped into this theme were those that reflect evidence-based teaching practice and are applicable in a broad range of teaching, such as PBL teaching and formal lectures. Items presented in the other two themes of the questionnaire were constructed to be more uniquely relevant to the type of teaching that occurs within dental clinical sessions, when student clinicians complete patient care, such as clinical demonstrations of patient care and clinical interactivity. An example of a questionnaire item in the theme of “the teacher/student relationship” was the following: “empathic guidance from the clinical supervisor supports student preparation for independent practice of clinical dentistry.” The final theme explored in the questionnaire was the range of skills required for clinical practice, namely decision-making skills, technical finemotor skills, communication skills, broad knowledge base, critical appreciation of evidence-based practice, and skills in self-assessment and self-confidence. An example of a questionnaire item in this theme was the following: “whilst many skills are impor-
Journal of Dental Education ■ Volume 69, Number 12
tant for dental clinical practice, the most important part of dental clinical practice is decision-making.” The questionnaire utilized a six-point Likert attitude scale providing responses ranging from 1 (always agree) to 6 (strongly disagree) and was refined based on the qualitative data derived from focus group discussions. The questionnaire featured twenty-five items about dental clinical teaching. These statements appear in the left hand columns of Tables 2, 3, and 4. These statements aimed to determine the strength of agreement with some of the comments made during the focus group discussions in regard to the usefulness of various dental clinical styles employed by faculty. B.Dent. and B.D.S. students and teachers completed the anonymous questionnaires. The response rate from B.Dent. students was unfortunately too low to be of value in the study, and these data were abandoned. Comparative demographic data of the B.D.S. student and teacher groups are shown in Table 1. In summary, forty-five B.D.S. students completed the questionnaires (response rate of 76 percent). Twentyone teachers completed the questionnaires (response rate of approximately 69 percent, taking into account the relative availability of fractionally appointed teachers to complete the questionnaire). A short briefing about the study was delivered to the students in both programs at the end of a lecture during a teaching semester, and students were then invited to participate in the questionnaire. The study was described to individual teachers who were invited to participate in the study by one of the researchers. All participants were asked to return their completed questionnaires to the researchers. Scores from the questionnaire for the different groups were analyzed to provide comparisons using Student t-test with Bonferroni correction setting P
