By Nicole Fauteux
“Miracle on 24th Street”—That is what Ralph V. Katz, D.M.D., M.P.H., Ph.D., called the implementation of a four-year curriculum in evidence-based dentistry (EBD) at New York University (NYU) College of Dentistry in a 2006 article in the Journal of Evidence Based Dental Practice. He did not attribute the school’s curricular transformation to divine intervention but rather to a “trinity of favorable circumstances” embodied by a visionary dean (Michael C. Alfano, D.M.D., Ph.D.); an innovative curriculum expert (Frederick G. More, D.D.S., M.S.); and a high-energy reformer (Richard I. Vogel, D.M.D.).
Dr. Katz credits these three individuals with creating the environment that allowed him and others to devise the predoctoral EBD curriculum that permeates NYU today. The Professor and Chair of the Department of Epidemiology and Health Promotion arrived at NYU’s College of Dentistry in 2000 with a ready-made method for teaching literature appraisal. His course, “Skills in Assessing the Professional Literature (SAPL),” which he had developed for dental residents at the U.S. Army Institute of Dental Research at the Walter Reed U.S. Army Medical Center, grew out of his own frustration because he did not receive similar training while earning his Ph.D.
“Any dentist can learn to read a summary article,” he contends, “but if you don't have the skills to read an individual article, what do you do during the ten-year gap between the time a clinical question occurs and the time a summary article appears?”;
The SAPL approach covers the full range of literature-appraisal skills, including study design and how to determine the utility of findings in treating a particular patient. NYU devotes a full 78 hours of curricular time to SAPL across all four years, and students must pass a competency exam to demonstrate their SAPL skills. These requirements form the foundation for additional EBD activities in NYU classrooms and clinics.
EBD gained visibility at NYU when the College of Dentistry incorporated NYU's College of Nursing in 2005. Together they created the Evidence-Based Practice Steering Committee as a way for faculty from the two entities to explore an area of mutual interest. The group continues to meet regularly, spreading the gospel of evidence-based practice (EBP). Several members received EBP training from McMaster University in Ontario, Canada, and a subset of those traveled to Oxford University in the United Kingdom for a course specific to dentistry. These in-house experts have subsequently trained or provided some exposure in EBD to about one-third of the dental school faculty.
“It has changed what's going on in the classroom and the clinic,” says Analia Veitz-Keenan, Clinical Associate Professor of Oral and Maxillofacial Pathology, Radiology, and Medicine. “The mentality has changed to: We have to look for the best available evidence. Even the students are more demanding.”
Dr. Veitz-Keenan is one of the EBP steering committee’s original members who received training abroad. She works in NYU’s Admissions Clinic, one of the first units to put EBD into practice at the college. The clinic’s faculty looked at its policy regarding radiographs for new patients, gathered the best evidence on which radiographs were appropriate, and developed a new protocol based on their findings. Dr. Veitz-Keenan laughs as she recounts that it took close to one year to complete the policy change in this methodical fashion, not to mention the faculty training required to ensure that the new guidelines were accepted and followed.
“Every time you want to do something new, even if it is based on evidence, some will be for it and some against,” she says philosophically. Still she believes NYU’s commitment to EBD is paying off.
Another offshoot of the EBP steering committee was the creation of two case-evaluation assignments modeled on a capstone project in place at the nursing school.
“In the third year, we ask the dental students to pull together everything that they've learned about risk identification and assessment, about how to find the evidence for a clinical question in the literature,” says Ivy D. Peltz, D.D.S., M.S.Ed., Clinical Associate Professor of Cariology and Comprehensive Care. “Then in the fourth year, they take that one step farther and apply that to one of their patients, their clinical decision making, and what the outcomes were.”
The result is two written portfolio cases that force the students to think critically and synthesize information. Unlike traditional literature assessment tools that allow students to fill in a template, these assignments force students to present their thinking in writing. Dr. Peltz, who is involved in this part of the EBD curriculum, has a straightforward rationale for this emphasis on written communication.
“Students need to be able to write to an insurance company, to a specialist, to a patient. They have to be able to do it. It's embarrassing if they can't sound like an intelligent, educated person.”
Silvia E. Spivakovsky, D.D.S., Clinical Associate Professor of Oral and Maxillofacial Pathology, Radiology, and Medicine, and one of the original members of the EBP steering committee, has incorporated EBD in an unexpected portion of the curriculum: the review course she teaches to prepare students for Part II of the National Board Dental Examinations.
Dr. Spivakovsky was already using multidisciplinary cases in response to the learning preferences of the current generation of students. Then she started asking students to come up with clinical questions related to the dental portion of each case, to work in groups to critically appraise the relevant literature, and to come to consensus on the best answer.
“When the question comes from them, the whole process takes on a different dimension,” she observes, noting the engagement in EBD her students exhibit. “We are challenged in so many ways by new information. I want to make sure they have enough tools to be able to do EBD on their own.”
Mark S. Wolff, D.D.S., Ph.D., Professor and Chair of the Department of Cariology and Comprehensive Care, agrees that EBD is engaging students, and he sees benefits for the faculty as well.
"NYU has undergone a metamorphosis in the last decade,” he says. “It's for a lot of reasons, but I believe this move to EBD has been instrumental. Our students no longer accept the faculty saying, I want you to do it this way. They ask why. It keeps the faculty very much in tune with what's next.”
Dr. Veitz-Keenan is a prime example of this. In addition to promoting EBD, she has enrolled her private practice in NYU's Dental Practice Based Research Network. Prior to this experience, she thought she was doing everything based on the best available evidence.
“But in reality,” she says, “I was taking little pieces of the evidence. I was not fully analyzing the literature and statistics. Doing the research on my practice has made me realize how difficult this is.”
No doubt many established practitioners share that sentiment but are afraid that it might be true, but EBD should come more easily to the current generation of NYU graduates. Still the question remains. Will they employ the skills they've mastered in dental school once they enter practice?
Dr. Wolff fears that the pressures of complying with the expectations of employers and senior partners may discourage early practitioners from exercising their EBD skills.
“Instituting EBD may take more than massaging the dental school,” he speculates. “It may take massaging the external environment that gets imposed on those graduates as well.”
Dr. Wolff notes that schools are also creating some logistical barriers that will need to be overcome.
“We're making them exceptionally capable of searching the literature, and even dependent on it,” he says, “but we’re not providing them with the unfettered access to the library that they have at the university. That will prove a problem in the future.”
In the meantime, the EBD movement is taking root at many dental schools and continuing to thrive at NYU.
“There's a core faculty group that is really enthusiastic and spreading it,” says Dr. Peltz, “and it is certainly being spread among the students. The ones who aren't buying in, they’re the outliers instead of the other way around.”
So does it take “a miracle for a school to be able to pull this off” as Dr. Katz likes to say? Perhaps, or maybe it just takes a fierce commitment by a core group of people, systematic hard work, and support from the top. Could these elements bring an EBD “miracle” to a school near you?