By Nicole Fauteux
How does a research scientist with a degree in physiology who spent more than a decade conducting NASA- and National Institutes of Health-funded bone research become a leader in ethics education? In the case of Lawrence Garetto, M.S., Ph.D., FACD, Professor of Oral Pathology, Medicine and Radiology at Indiana University School of Dentistry (IUSD), the answer appears to lie in a series of fortuitous events.
In 1993, IUSD started to discuss introducing small group learning in the dental school curriculum. Dr. Garetto had experienced problem-based learning (PBL) while doing post-graduate work at the University of California, Davis, making him one of two or three people on the faculty familiar with the approach. Additionally, he held a joint appointment in the School of Medicine, which had already adopted PBL. Dr. Garetto’s relative expertise and his enthusiasm for the PBL curriculum that IUSD would eventually adopt set him on the path that would lead from research to curriculum design and eventually to ethics.
By 2004, Dr. Garretto had become Associate Dean for Dental Education and Director of the Problem-Based Learning program at the School of Dentistry. From 2006 to 2008, he served as President of the American Society for Dental Ethics, and he continues to represent the organization as Liaison to the Board of Regents of the American College of Dentists. Earlier this year, he spoke with the ADEA CCI Liaison Ledger about his career and the attitudes of today’s students toward ethics and professionalism.
Q: When and why did you develop an interest in teaching ethics and professionalism?
A: In 1997, we changed our curriculum to a small group-learning environment. The new curriculum placed a high degree of importance on self-motivation and on individuals initiating their own learning. Because of the new focus on student-centeredness, in 1998, we started talking about what was going to be called the Student Professional Conduct Committee, which would act as a peer review group in the case of academic or professional conduct issues.
At the time, the majority of schools had a purely administrative model where administrators sat in judgment of students. Some schools had a conduct committee incorporating a couple of students. But other than IUSD and Michigan, I don’t believe any dental school had a peer-review committee comprised entirely of students.
The learning process of getting ready for that introduced me to Dr. David Ozar. David, who is a philosopher-ethicist based at Loyola University in Chicago, is probably the father of dental ethics in modern times. David has been both a mentor and a close friend ever since. My interactions with him moved me into ethics.
Shortly after that, I took over the “Introduction to Critical Thinking and Professional Behavior” course, and that kicked me into high gear in terms of the professional ethics environment because, now, not only was I learning about it, I was teaching it.
Q: How did the new curriculum affect the way ethics is taught at IUSD?
A: In dentistry we have focused primarily on professional ethics. That focuses on the attributes and obligations of a dental professional. We’re not talking about a specific patient when we’re doing that. We’re talking about ourselves and our responsibilities to patients in general, and ourselves and our responsibilities to each other and to society, and dentistry does that magnificently.
In the early 2000s, we started writing our own cases and we created a template where ethics and behavioral sciences became two discipline areas that were taught in every PBL case, and we essentially taught ethics and behavioral sciences through those cases.
In 2007, we crafted a relatively novel competency approach to ethics that took into account this marvelous protected time we had right at the start of the curriculum—”Introduction to Critical Thinking and Professional Behavior” is the only course students initially take when they first arrive on campus—and then these 40 PBL cases, each of which had ethics.
Q: How has the IUSD ethics curriculum evolved in recent years?
A: When we started our self-study for this current accreditation (completed in 2013), we started talking about, “What are we still not doing that we need to do?” It was very clear to us that our students left the second year of the curriculum and went into the clinic in year three and probably never thought about ethics again except when pressed to do so. There was very little follow-through into the clinical years. There was professionalism stuff, but we weren’t talking about ethics in the third and fourth year, and we were never talking about ethics associated with a particular patient.
About that time, I came out of my academic deanship, and in 2011–12, I did a fellowship in our hospital system in clinical ethics—the field that looks at the ethical dimensions of care for the particular patient you’re treating. Clinical ethics has been a developed field in medicine for probably 40 years.
Since August 2012, we have had weekly discussions about ethics with our junior and senior dental students. Twice a semester, I meet with each group practice and the clinical director. We talk about the cases they’re seeing, and I ask questions like, “What’s the ethics question here? What are the options in looking at this patient? What values guide us? Which option has the most pros and the least cons? Is it possible to implement?” It’s an analysis process.
The conversations are sometimes just the most engaging things you can imagine and once in a while it’s like watching paint dry. It’s not 100%, but it’s better than 80%, so, from my perspective, it’s really working well. So now we have a four-year ethics curriculum where they’re talking about the actual application of ethics in the care of patients, and that’s what this has to be about.
Q: How did you get involved with the Student Professionalism and Ethics Association (SPEA), formerly the Student Professionalism and Ethics Club (SPEC)?
A: I got involved with SPEC a year after they formed. One of my closest friends is Al Rosenblum [faculty advisor to the first SPEC chapter, which was formed at the Ostrow School of Dentistry of the University of Southern California (OSD USC)]. OSD USC was the only other large school doing problem-based learning in the early to mid 2000s. That’s how Al and I met and discovered we shared this interest in ethics.
I remember vividly asking Al, “How did SPEC get started?” OSD USC had a professional conduct system that a group of students felt wasn’t working as well as it could, and instead of protesting, they decided to start a study club about ethics. Once SPEC was established, they created SPEC start-up kits that other schools could use to start clubs on their campuses. That method sort of worked, and I tried for a few years to get a group started at IUSD with almost no luck. It took the right mix of students and a critical mass to get the club going. I’m currently the advisor for our SPEA chapter at IUSD. We’ve gone from around 8 to 10 students at our monthly sessions to 90 students at the last one.
Q: SPEA is now a national student-run association with affiliated chapters on about three dozen campuses. How is SPEA changing the dental education landscape?
A: I think it’s part of an environment change. The more we view our students as colleagues-in-training, and the more we extend to them the responsibility that they should be taking on as they move out of school, the better off we are. The benefit of SPEA and the benefit of a professional conduct system that involves students is that they are living that part of professional life that makes professions unique: societally granted self-regulation.
In the olden days, we kept all the power about the professional aspects of dentistry to ourselves as faculty. The students graduated, and somehow we expected a switch to get flipped and they would act like professionals, they would do peer review and be self-regulating. Well, baloney! It doesn’t happen that way. It’s a learning process just like learning about chemistry or learning a hand skill. You have to learn what the professional aspects are, and you have to live the responsibility in order for the responsibility to take hold. It’s not good enough to say, these are the things you have to do and not ever have them do it until they graduate.
Q: What changes have you seen since the revelations about cheating in dental schools that made national news in 2007?
A: We were one of the schools that had a fairly substantial cheating scandal in 2007. We handled it well, but we had to discipline 46 students. Even in a school that had strong student involvement in the professionalism system, we still had a lapse like that. These things are a part of human nature. Schools that do the best [when it comes to breaches in ethical and professional behavior] work to try and understand why it happened and make changes to deal with that. And they recognize that human beings screw up.
I hope that ethics education has an impact, but there’s not 100% participation. There’s not 100% acceptance that ethics is important, but with the constant presence of something like SPEA, at least the discussion happens on a relatively frequent basis, and with frequent discussion comes the opportunity for that momentary pause when you say to yourself, I can do this ... should I do it?
Q: What are the biggest challenges that lie ahead?
A: One of the things I hear once in a while is, “Our students are here to learn. We’re sidetracking them with all this other stuff.” I can’t tell you how strongly I disagree with that sentiment. I absolutely agree that our students are here to learn, and one of the things they’ve got to learn is how to be a professional person. You can’t just lecture them and give them stories to read and expect them to learn from that. They have to practice being professional people.