By Dr. Robert J. Hinton, Baylor College of Dentistry
Within the last five to ten years, the incorporation of the best available evidence into the treatment decision has gained considerable visibility and momentum in the dental community. This is reflected in an increasing emphasis on evidence-based dentistry (EBD) at the American Dental Association (ADA), programming at last year’s ADEA Annual Session, and by accrediting bodies such as the Commission on Dental Accreditation (CODA). The growing national prominence of EBD has in turn spurred dental educators to include EBD content in the curriculum.
Texas A&M’s Baylor College of Dentistry began this process in 2008 with support from a grant from the National Institute of Dental and Craniofacial Research (NIDCR). From the beginning, we were acutely aware that devising the curricular experiences for students would not be our greatest challenge. Rather, we knew that getting our clinical faculty – who must model EBD during the D3 and D4 years – to acquire the tools of EBD and to appreciate its value would be the more daunting task.
Dental schools have traditionally provided little incentive for clinical faculty to learn EBD. Unlike students, they are not getting a degree, and any contribution of this activity to their career advancement may not be apparent. Second, some clinical faculty come with negative preconceptions about EBD-- “it will dictate how I practice,” “I hated statistics in dental school,” “I hear that there is little evidence anyway”--and understandably, most clinical faculty feel that they are too busy to undertake an extensive course like the one we offer students (32 lecture hours plus small group sessions). Finally—and perhaps most problematic—clinical faculty may feel uncomfortable or even demeaned by being “taught” by faculty colleagues at their level or below, including some non-clinicians!
What to Do?
As the leader of our EBD initiative, I realized that clinical faculty participation and buy-in would determine whether EBD became incorporated into the school culture or was regarded as just another “box” to check off. With this in mind, several colleagues and I designed an informal course on the fundamentals of EBD for clinical faculty with the goals of equipping faculty to effectively interact with students and introduce EBD content into their teaching. A hallmark of the course structure was the incorporation of adult learning techniques such as discussion and hands-on experiences wherever possible. Although delivery of some content in a lecture format was unavoidable, interaction was encouraged during lectures, and multiple sessions featured discussion of clinical research articles. A medical librarian used hands-on instruction to demonstrate how to optimally search PubMed and similar databases. And as the capstone experience, each participant presented a Critically Appraised Topic (CAT) on a topic of his/her choosing.
The course met during summer semester (the least busy time for most of our faculty) from 8:00-9:30 AM (prior to the opening of most clinics). Recordings of PowerPoint presentations with audio for each lecture were archived for those who had to miss. This was summer after all! Meeting twice a week for around eight weeks afforded participants time to digest the material and to formulate and work on their CAT presentation as their knowledge base increased. As presenters and facilitators, we made every effort to keep it collegial, avoiding the excessive use of unnecessary jargon and examples that might be perceived as demeaning. And, of course, we made sure our clinical faculty got CE credit!
How Did It Go?
In any new endeavor, one’s best efforts can almost always be improved upon. Focus groups conducted annually by an assessment specialist, coupled with our own observations, provided insights that have informed what we now do in our fourth iteration of the course. We have realized that it is critical that all content be designed for ‘users’ (consumers of research articles who use research to inform treatment decisions) instead of ‘doers’ (investigators conducting clinical research). Accordingly, we have progressively focused on elements of statistics and epidemiology that emphasize those concepts important to assessing research results (e.g., importance of a power analysis, sampling, risk ratio, intent to treat). We also stress research design and the hierarchy of evidence, i.e., the tools needed to assess research rather to perform research.
Based on participant feedback, we reordered our course to frontload PubMed searching, and we begin with a course overview rather than starting with first principles such as statistics. We have also learned that articles involving clinical dentistry almost always generate more interest among our participants than articles with an epidemiological focus. This interest is vital!
Finally, it is highly desirable to include influential faculty and if possible department chairs among course participants. These faculty can serve as champions for promoting the initiative school wide and for recruiting future course participants. During our second year, attendance by the Chair of Restorative Sciences with several faculty in tow was pivotal in bringing our effort to the mainstream.
The response from our clinical faculty has been gratifying. One noted that “[I learned] how to objectively approach a clinical question” while another commented on feeling empowered after learning how to perform online searches, remarking that “Everybody should know how to do this!” Other comments suggest that the course affected how faculty see themselves. One read, “[The course] took away the barrier I had to review articles (a strong sense of inadequacy).” Another, “A sealant article I have clung to turned out to not be so good. I have moved from being a practitioner to an educator; teaching to dental students is at a whole different level than to patients”.
The evidence that we have truly achieved an “EBD culture” at our institution is still incomplete, but I am encouraged by the fact that several past course participants are implementing EBD content in course work, by the increasing acceptance by students of EBD as “what we do,” and by the heightened visibility of EBD in the form of school retreats and health science center initiatives. Although a gradual process, I feel that our EBD curriculum will endow our students with concrete tools to assist in lifelong learning, revitalize our clinical faculty, and ultimately improve the quality of care delivered to our patients.