The anatomy of a new dental curriculum

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Mar 7, 2008 - dental degree programme on socio-cul ... then goes on to explain how these theo ries are ... In everyday life, we all know that the. 'who done it?
IN BRIEF

• •

J. McHarg1 and E. J. Kay2 •

Examines what knowledge, skills and attributes are required of our graduating dentists for best practice in treating patients. Uses evidence- and research-based educational theory to best develop the knowledge, skills and attributes needed by our students. Every student gets individual and regular feedback on all aspects of their progress from the ‘community of practice’ which makes up the school staff.

The goal of all dental schools is to develop competent, knowledgeable dentists who have excellent communication skills and a sense of social responsibility. This paper describes the theoretical reasoning behind the design of an innovative dental curriculum constructed from first principles in the UK. The recognised theories of psychologists, educationalists and sociologists of the twentieth century have informed our educational decisions. In practice, this translates to a blended learning environment with problem-based learning (PBL) case scenarios at its heart. The learning of clinical and communi­ cation skills, which begins in year 1, week 1, is absolutely integral to the case scenarios, as are ethics and professionalism. PBL is supported by a comprehensive e-learning platform, plenary lectures, workshops, clinical and life science teaching delivered by core academic staff and guest speakers who are the experts in our ‘community of practice’ in which the stu­ dents are the novices. We believe that the whole is best described as ‘enquiry-based learning’.

Introduction Dental graduates need to have theoreti­ cal and practical understanding of the practice of dentistry, enabling them to act safely and beneficially as health care professionals. It is therefore incumbent on us to find the best way to develop dental students to this end. With the creation of a new dental school in the UK, the opportunity has arisen to base a dental degree programme on socio-cul­ tural approaches to learning. It has been possible, by drawing on learning theory and research, to base a programme on the way people actually learn in eve­ ryday life. The resulting programme recognises learning as a social process, and not one which is remote from prac­ tical reality. It is based on the premise that learning occurs as a result of

1* Year 1 Lead, Peninsula Dental School, Portland Square, University of Plymouth, Plymouth, PL4 8AA; 2Dean, Peninsula Dental School, John Bull Building, Tamar Sci­ ence Park, Research Way, Derriford, Plymouth, PL6 8BU *Correspondence to: Dr Jane McHarg Email: [email protected]

Refereed Paper Accepted 7 March 2008 DOI: 10.1038/sj.bdj.2008.464 © British Dental Journal 2008; 204: 635-638

interactions between peers, staff, those at home, and in the case of dentistry, patients. Most importantly it is founded on the principle that learning is not a process of ‘transmission’ of information from teacher to learner.1-4 Furthermore the programme recognises that develop­ ing information into knowledge requires an understanding of the different types of knowledge5 (tacit, structured, situ­ ated, codified, disciplinary, pedagogic) and of the way people learn. This paper describes the learning the­ ories drawn upon to create the Peninsula Dental School (PDS) curriculum and then goes on to explain how these theo­ ries are operationalised into an effective blended learning environment.

Theories in education and learning Health care professionals and educa­ tional institutions are both potentially agents of social change.6 Thus, to draw on theories of education for social change is an obvious starting point. A human­ istic standpoint which recognises the value of people is also crucial to educa­ tion for health, since health care is ulti­ mately about people and their welfare.7 The Peninsula Dental School has there­ fore adopted the humanistic philosophy

of Paolo Freire1 as the guiding principle in the design of the school’s learning cul­ ture, in order to create a dental school in which everyone – staff, students and patients – feels content and has high self­ esteem, and also trusts others and feels concern for them.8 Following the adop­ tion of these central guiding principles, the work of many educationalists and psychologists of the twentieth century informed the design of the curriculum.

The thoughts of Paolo Freire In essence Freirean philosophy is about the liberation of the individual by learn­ ing. In order to become good learners individuals have to take responsibility for their own learning and develop meta­ cognition. They not only know what they know, they know how they learn and critically reflect on all aspects of their learning. Although about individuals, the philosophy recognises that ‘knowing’ is a social process involving not only others’ knowledge but others’ feelings and beliefs. Through critical conscious­ ness individuals can use their knowledge to help their fellow humans. Freire’s the­ ories are based on a lifetime of educating the underclasses in Brazil and he was not alone in his conclusions. They echo the

BRITISH DENTAL JOURNAL VOLUME 204 NO. 11 JUN 14 2008

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EDUCATION

The anatomy of a new dental curriculum

EDUCATION

very similar concept of ‘self-actualisation and transcendence’ of the learner, expressed by Maslow in his body of work on the hierarchy of needs.2,3 In the dental education context this means that the student learns to per­ ceive social, health and environmental issues and takes action to mitigate their negative effects on oral disease. In a practical and vocational profession such as dentistry the link between conscious­ ness raising and action is important. It is insufficient for a practitioner to understand and explain the detrimental effects of dietary sugars on oral health. S/he must also have the ‘know how’ and skills, to take effective action to reduce the effects of the damaging substances. This link between being conscious of a problem and taking appropriate action Freire terms ‘praxis’, which implies that there is an interactive process of reflec­ tion and action, a concept expounded by many others.9-11 The application of this concept to dentistry is all too obvious. Action without reflection would imply intervention without cognisance of the outcome, whereas, reflection without action would mean that dental prob­ lems could be described, explained and intellectualised, but not solved.

Posing a problem promotes enquiry In everyday life, we all know that the ‘who done it?’ or a good puzzle excites the curiosity and makes us want to fi nd out more. Using this tool, Freire posited that presenting problems for students to solve promotes enquiry and engages them in learning. Taking his thesis a step further he proposed that in problem solv­ ing learners should be allowed to control their own learning, which would pro­ mote effective acquisition of many types of knowledge. Freire believed that this ownership would lead to deep learning when the learner understands underlying meanings, relates what s/he has learnt previously to new knowledge and, impor­ tantly, can organise ideas and knowl­ edge into a holistic approach to a given problem. In dental education, adopting Freirean principles requires that the tra­ ditionally accepted inequality between teachers and learners is dismissed. Abso­ lute equality between students and staff with no sense of the ‘possessor/giver of 636

knowledge’ and ‘receiver of knowledge’ is an essential to enquiry based learning. In a dental school, the ideal setting for this type of learning is a community of people who all genuinely wish learn­ ing to take place and recognise that there are no hierarchies, and no one person is more important than another in the learning community - they simply have different roles.

Situated learning Built upon the constructivist and activity theories of learning,12-14 Lave and Wenger proposed the theory of situated learn­ ing.15 This hypothesis is that ‘everyday’ unconscious learning occurs by reference to activity, context and the culture in which it takes place. That is, it is situated. Central to the theory are two principles: firstly that learning requires social inter­ action and that learners become involved in a ‘community of practice’. Secondly, that knowledge needs to be presented in an authentic context. Joining the ‘community of practice’ enables learners to move from novice to expert through observing, rehearsing and reflecting. Importantly, the learner does not learn in isolation by ‘doing’ alone which is a large part of the construction of experience, but with the invaluable feedback of others in the ‘community of practice’. In their research Lave and Wenger observed that new joiners to a community learned at the periphery and as they became more competent they moved more to the centre. It is a socialis­ ing, cultural journey in which the learn­ ing of knowledge, skills and attitudes are embedded, and it is pertinent to training in any profession or trade. Bleakley stud­ ied the first apprenticeship year (pre-reg­ istration house officer, now F1) of new qualified doctors.16 He found that the tra­ ditional model of transmission of knowl­ edge from one individual to another did not sufficiently describe the process of how work-based learning occurs. The socialisation into the profession occurs through novices co-constructing knowl­ edge with several different experts. In so doing, the novice moves towards con­ structing the identity of the expert for themselves. In the case of dentistry, it is about learning to be a dentist not learn­ ing about oral science.

A key skill for dentists is the ability to transfer what they know and what they can do to new situations. It is also essen­ tial that the learner is able to develop new competencies throughout their career. Thus, dental schools must empower their students to learn in ways which reduce their dependency on formal teaching and increase their ability to learn from expe­ rience and reflective investigation. The above concepts suggest that facil­ itation of the learners’ ability to shift frameworks and, in doing so, reorgan­ ise or reconstitute what s/he knows is a crucial objective. That is, the learner does not repeatedly take a jigsaw apart and redo it, but takes it apart and uses the pieces to create a new picture. Thus, it seems that deep learning takes place through experiencing new and difficult situations which generate ‘puzzlement’.17 This ‘puzzlement’ or confusion can be used by the situated learner to create a series of questions, a process which stimulates the learner’s interest and motivates them to learn. This in turn results in the learner producing poten­ tial ‘answers’ and alternative explana­ tions. The ability to deal with difference, together with the recognition of similar­ ity, is symptomatic of deep learning. In such a vocational subject as den­ tistry, the value of making knowledge available in context needs no explana­ tion. The possibilities for immersing den­ tal students in fully situated contexts are virtually limitless. However, in designing a curriculum an awareness of the dif­ ferent types of knowledge and how and where they are relevant to the practice of dentistry is useful. Figure 1 gives a clas­ sification of knowledge with dental exam­ ples. A commonly stated example, which is perhaps analogous to dentistry, is that one can have (explicit) knowledge about bicycles, but this is irrelevant to the abil­ ity to ride a bicycle (tacit knowledge).18 Likewise, one may have an explicit knowledge of tooth structure and dental caries but this does not necessarily imply that the ‘knower’ would have any ability to remove the decay and repair the tooth.

The Peninsula programme The appropriateness of the above edu­ cational theories and conceptual frame­ works to dental education was the BRITISH DENTAL JOURNAL VOLUME 204 NO. 11 JUN 14 2008

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Fig. 1 Classification of knowledge and examples in dentistry Disciplinary knowledge

The knowledge of a certain discipline/academic knowledge eg knowing the epidemiology of dental diseases

Pedagogic knowledge

Knowledge which is arranged in a way which assists the learner eg a study guide

Procedural knowledge

The knowledge of how, and how best, to perform some task eg knowing how to give a painless injection

Propositional knowledge

The knowledge of truths which can be stated eg sugar causes caries

Practical knowledge

The knowledge of physical attributes of something eg knowing how to remove caries with a high speed handpiece

Tacit knowledge

The almost unconscious knowledge of how to do an activity eg how much pressure to exert on a handpiece to cut through enamel

Situational knowledge

Knowledge of a specific situation eg knowing how to move the forceps to extract a four rooted permanent molar

Codified knowledge

Scientific or research based knowledge eg knowing how a nerve impulse is conducted

driving force in the Peninsula Dental School curriculum design.

Enquiry-based learning in the dental curriculum Having adopted the Freirean principle of problem-posing as a guiding principle, PBL19,20 was an obvious method of choice to deliver the curriculum. In each year of the programme there are between 10 and 20 patient case scenarios based on a life-cycle approach (infancy to old age), in which the physical, functional and psycho-social aspects of the patient’s life are described or implied. The desired learning outcomes for each scenario are mapped onto the GDC’s learning out­ comes described in the document The first five years.21 In year 1 each case takes two weeks, but as successive years’ sce­ narios become increasingly complex and students spend up to four days a week in the clinic, it is envisaged that cases may take three or four weeks. The whole learning environment is supported by an e-learning platform. Working in groups of eight with a trained facilitator who is also a dentist, students are given the time, space and electronic shared space to ‘decode’ the scenario. Collectively, the group derives learning issues all of which they indi­ vidually investigate and learn in their allocated self-directed learning time. This broad model of PBL has been well tested over the past 30 years world­ wide,19,20 initially in medical schools and

latterly in many disciplines including dentistry.22-24 Students, as a group, must derive their own learning outcomes and are encouraged to work as collabora­ tively as possible sharing the knowledge and sources of information throughout the case, via their electronic space in addition to their face-to-face meetings. They are expected to regard each other and the facilitator as respected equals. In decoding the scenario, students follow a template known as the seven steps.25 In short, the group identifies what the sce­ nario is about and creates a mindmap26 of all the issues brought up by the case. These obviously include the psycho­ social aspects together with the purely clinical aspects of the scenario. Collabo­ ration is beneficial because those stu­ dents who major on the clinical aspects gain insight from those who major on the psycho-social aspects and vice versa. It is important that students iden­ tify three areas: the issues raised by the scenario, what they know already about the issues, and the concepts which link them. Through this process, the group can then decide together the ‘fi nding out’ and learning they must do individually before the next meeting. Feeding back to the group and sharing knowledge takes place during subsequent meetings dur­ ing the case, which gives the facilita­ tor the opportunity to assess how much work and learning each individual has achieved. Students are encouraged to feed back to the group without reference

to detailed notes, because if they have ‘learnt’ something it should be in their heads as well as in their notebooks! PBL has been extended at PDS to encompass an additional experience at the end of each case, thus complet­ ing the cycle of learning. It is believed that deep learning is exemplified by the ability to reconfigure knowledge learned in one situation and use it in another.16 Students are presented with a scenario, which is different from the first but which tests the same knowledge and attitudes. Whereas the PBL process has been one promoting learning and not necessarily resulting in the resolution of a problem, the second scenario is designed so that the knowledge and attitudes gained in the first process enable the students to propose a plan of action to address the issues raised in the second scenario. In order to present the plan, students should not need to carry out new research or learning if they have learned enough from the first scenario. After presenta­ tion of the plan each student reflects on their performance throughout the two weeks in terms of achievement of the agreed learning outcomes, contribution to the group, their knowledge develop­ ment, and how they handled the second case (thereby demonstrating the depth of their learning). In one-to-one dis­ cussion, the facilitator offers immedi­ ate feedback on how the students have performed. In this way students slipping below the ‘waterline’ are identified rap­ idly and given early remediation by an experienced member of staff. Students are also encouraged to give constructive feedback on performance to each other every two to three weeks, which allows the group to self-regulate with all the benefits that peer assessment brings. During each case there are plenary lectures, workshop sessions and in depth life science teaching. These are always in a context relating to the case and are intended as a whole to both broaden and focus knowledge and attitudes. Work­ shops cover professionalism, ethical issues and communication skills, often using roleplay and ‘theatre in education’ techniques. Plenaries serve as signposts to what students should be learning, both in direction and in depth of knowl­ edge and understanding. An uncertainty

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which PBL students have is at what depth to learn: being able to take a lead from the plenaries goes some way to allevi­ ate the uncertainty. Half of the plenaries is given by outside speakers chosen for their expertise whether it be a general dental practitioner on dental decay or a consultant immunologist on HIV. The rest are given by core staff. We expect all our speakers, teachers, and learn­ ing facilitators to be good role models in their professionalism, knowledge and attitudes and we have an induction pro­ gramme to introduce them to the ethos of the school. They are the experts in the ‘community of practice’ in which the students are the novice learners. The evolution of Freirean principles, PBL, ideas from the literature on situated learning and our own experiences of how enquiry drives ‘every day’ learning have led us to call this blended learning approach ‘enquiry-based learning’.

Clinical skills and professionalism The learning of clinical skills from week 1 of year 1 of the programme is seen as absolutely integral to the PBL process, as the aim is to make acquisition of knowl­ edge, skills and attitudes as seamless as possible. In order for this to happen the case scenarios are written so that the learning issues generated by the ‘story’ work in synergy with the clinical skills learnt. For each case, students are faced with either a relevant practical clinical exercise in the phantom head room, or a patient in the clinic who has a problem similar to that described in the scenario. Therefore the student needs to reflect on their learning, take action and exhibit both explicit and tacit knowledge about how to deal with the problem. This ‘learning by doing’ is accompanied by ‘tell, show, do’ teaching by a clinical supervisor and followed by immediate feedback on performance. In the case of the simulated exercise, the feedback relates only to the technical work, but in the case of patients relates to patient care and management in addition to technical ability. All techniques are competency tested in the phantom head room before being used with patients.

638

Dependent upon when each student feels ready, students choose when to demonstrate their competency to a tutor who assesses their performance and again gives immediate feedback. In the first year, 12 clinical supervi­ sors have been recruited to ‘teach’ clini­ cal skills on limited hours from the local dental community, both NHS and pri­ vate. The aim is to socialise the students into the profession from the start of year 1 by learning with these experts. Each six weeks students meet with their academic tutor, having reflected on their progress and development of professionalism in all aspects of the programme: clinical skills, knowledge development, collaborative learning and patient care. Together, tutor and student decide on appropriate action (praxis) for improvement. This is a formal docu­ mented process, which forms part of the ‘personal and professional development’ assessment module. Students are graded ‘satisfactory’, ‘borderline’ or ‘unsatis­ factory’ and any student falling below ‘satisfactory’ must have remediation, by an appropriate member of staff. In this way the experts in the ‘community of practice’ give continuous feedback to the novices on their professional journey.

context and supported by a ‘community of practice’, which recognises its role in modelling professionalism and support­ ing the students on their journey from novice to expert. 1. 2. 3. 4. 5.

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Conclusion The aim of this paper is to explain and disseminate the theory underpinning the ethos, teaching philosophy, method­ ology and design of the UK’s fi rst new dental school for 40 years. Whilst the curriculum has not yet been tested in the market place – no graduates of the school are yet safely employed – it is hoped that its graduates will be multi­ talented, highly skilled and fit-for-pur­ pose. We have some confidence in this being the case, because the curriculum has been designed from fi rst principles with the aim of producing dentists for the twenty-first century. It is based on educational theory which promotes the acquisition of deep and meaningful knowledge, not only as a dental student, but for a lifetime of learning. Learning opportunities for knowledge, skills and attitudes are situated in an authentic

17. 18.

19. 20. 21.

22. 23. 24. 25. 26.

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