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Educator Spotlight: Dr. Stuart Schrader

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By Nicole Fauteux

Historically, people with cognitive, hearing or visual impairments have been directed to seek out a special care dentist or a dental school for their oral health needs. Do these referrals occur because general dentists lack the dental knowledge and skills to treat these patients? In some cases, yes, but more often dentists are simply unfamiliar with these populations and lack targeted training in how to communicate effectively with special needs patients.
Stuart Schrader

The work of Stuart Schrader, Ph.D., Clinical Assistant Professor of Behavioral Sciences at the Indiana University School of Dentistry (IUSD), suggests that cultural competency training can remedy this situation. In 2010, Dr. Schrader and his colleagues started integrating patients with special care needs into an established program of objective structured clinical examinations (OSCEs), but the story of how that program came about actually starts much earlier.

“In 2005, the dental school was transitioning between deans and looking ahead to its accreditation,” Dr. Schrader recalls. “They hadn’t had a full-time behavioral scientist at the school for a while, so they were interested in the things I was doing.”

In addition to his degrees in psychology, organizational communication, oncology social work and health care communication, Dr. Schrader offered the dental school his skills as an educator, already honed at the Indiana University School of Medicine, among other institutions; his expertise in creating OSCEs; and his experience addressing the psychosocial needs of cancer patients and people living with HIV/AIDS.

It wasn’t long before Dr. Schrader and an IUSD colleague, David Zahl, M.A., Curriculum and OSCE Specialist in the Office of Academic Affairs, began exploring how they might introduce the behavioral patient management needs of people living with HIV/AIDS into the dental education curriculum. The creation of an OSCE immediately came to mind, but with a twist. Instead of using actors, they would create standardized patients drawn from the community.

“The idea was we would hire people living with HIV/AIDS to co-educate our students about their oral health care needs and to share what it’s like to live with an acute disease,” says Dr. Schrader. “We ended up working with a local care coordination agency whose patient population was intensely culturally diverse, so we were also able to help our students better understand the cultural complexities this population faced in accessing oral health care.”

The program was such a success that it received the 2010 Orna Shanley Prize for Enhancing Access to Care. The HIV/AIDS OSCE is still in place today as part of IUSD’s third-year dental curriculum.

The idea for the Special Care/Needs OSCE emerged when Dr. Schrader got to know Nichol Kirby, a graduate student at the Indiana University School of Social Work and an American Sign Language interpreter who has contributed to the design and implementation of the OSCEs. With his background in health communications, Dr. Schrader was fascinated by the work she was doing in health care settings to bridge the communication gap between hearing individuals and the Deaf community.

IUSD’s first Special Care/Needs OSCE focused on clinically interviewing patients living with cognitive disabilities and providing them with oral health prevention education. Following the model of the HIV/AIDS OSCE, IUSD formed a partnership with a local agency to recruit individuals living with Down syndrome, autism or cerebral palsy (or any combination of these) and trained them to act as standardized patients. All participants were “self-advocating,” meaning they were deemed capable of providing informed consent. Caregivers were also recruited and trained to act as standardized caregivers so they could assist the standardized patients in completing the oral and written assessments of student performance.

Unlike traditional OSCEs, the Special Care/Needs OSCEs are formative in nature and include substantial preparation. Students are introduced to the target community through guest speakers, training seminars, online videos, assigned readings or a combination of these methods. The students are also given patient charts and the list of OSCE objectives in advance. Each OSCE includes a 360-degree evaluation comprising a self-assessment, a peer assessment and an assessment by the standardized patient.

“All OSCEs operate on the principle that they are designed to catch outliers, and the patients catch those outliers,” Dr. Schrader reports. “The immediate patient feedback is the crux of the educational experience.”

The written self-assessment that follows the Special Care/Needs OSCE is also critical. Students are asked to assess their own performance against benchmarks they find in the research literature—some of it related to the specific population—on topics such as building rapport, interviewing patients and oral health education.

According to Dr. Schrader, medical education research shows that student scores on the OSCEs correlate with both their board and general exam scores. In addition to being a useful indicator of student progress at IUSD, data from the Special Care/Needs OSCEs also proved useful during the school’s recent accreditation. David Zahl mapped the OSCE data to relevant Commission on Dental Accreditation (CODA) standards, including those on patient-centered care, interpersonal communication, cultural competency and ethical sensitivity, and he presented a matrix that was well received by accreditors.

Since the launch of the first Special Care/Needs OSCE, IUSD has run four others, each of which involved patients from either the Deaf or the visually impaired community. All second-year dental students complete the OSCE, one of five needed for graduation.

“More than any other, I think the Special Care/Needs OSCE really touches who the students are as caring, compassionate people,” Dr. Schrader reflects. Many describe their concerns about family members with special needs in their reflective writing, and pre- and post-OSCE surveys of student knowledge and beliefs about the population encountered further confirm this observation. Dr. Schrader and his colleagues noted an especially large improvement in students’ survey responses following the first Special Care/Needs OSCE focused on visual impairment.

“We invited a legally blind speaker who arrived with a working dog,” Dr. Schrader recounts. “He gave this intensely articulate PowerPoint presentation about the stereotypes the people in the visual community have about the people in the visually impaired community. The students were just astounded. It generated a lot of good will, a lot of respect and intense, genuine interest in helping in a way that may not have otherwise occurred.”

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