Facing the Challenge of Incorporating Inter- and Intraprofessional Education

By LaShell Stratton-Childers, ADEA Senior Editor

Inter- and intraprofessional education are by no means new concepts. For decades, dental schools and allied dental programs have strived to integrate knowledge from other disciplines into their curricula and advocated for including oral health in other health professions’ curricula to better prepare students for real-world practice and to be more responsive to patients’ needs.

But dental and allied dental educators report that even with the best of intentions, they still face two big challenges to incorporating additional inter- and intraprofessional education into didactic coursework and clinical exercises: lack of time and competing priorities. However, the COVID-19 pandemic may offer the opportunity and a possible pathway to traverse these barriers.

Changing Spaces to Inspire Collaboration

A group of dental hygiene students at The Ohio State University College of Dentistry work in their Oral Health and Disease Prevention course, practicing hands-on application of the jigsaw classroom teaching strategy learning and utilizing evidence-based, interdental cleaning aids.

At The Ohio State University College of Dentistry (OSU COD), faculty are encouraging more collaboration between dental and dental hygiene students not just through coursework, but also through spatial arrangement. Dental and dental hygiene students take three classes together and have been doing so for years: Oral Anatomy, Tooth Morphology & Occlusion; Pain & Anxiety Management; and Practice Management.

Taking classes together was just the first step. Rebecca Henderson, B.S.D.H., M.S., Assistant Professor-Clinical in the Division of Dental Hygiene at OSU COD, said the college realized it also had to make changes to something as simple as the class seating chart to help accomplish more teamwork and conversation across disciplines.

Prof. Henderson noted that many years ago, dental students often had assigned seating in their courses for grading, so the dental hygiene students developed a habit of filling the seats around the dental students in the integrated courses, “which wasn’t an intentional delineation, but it turned into what felt like an intentional delineation of groups of students.” Subsequently, the instructors changed their seating charts so dental and dental hygiene students were more intermingled.

Dental and dental hygiene students also work together at OSU COD in the Expanded Functions Dental Auxiliary (EFDA) Clinic, where the dental students do the cavity preparation and the caries excavation, and the expanded functions students provide restoration. The EFDA Clinic Director works with the predoctoral Clinic Directors to identify patients who need restoration work that would be ideal for a dental student and an EFDA student to work on together.

The EFDA Clinic Director looks for cases that aren’t “too big or too complicated” for the students, Prof. Henderson said, particularly cases that don’t require a great deal of faculty intervention.

Prof. Henderson admitted, however, that often the dental and EFDA students do not interact or even discuss their respective cases together prior to the patient appointments, something the faculty at OSU COD hopes to change.

“Dental hygiene students do have huddle at the beginning of our clinic sessions to kind of plan and debrief with faculty members and talk about any challenges or have discussions,” she said. “I don’t know if the predoc students have a formal huddle with their faculty members prior to the clinic session, but I think informally they go through a similar clinic process where they talk through the goals and expectations and kind of plan the appointment. But that’s certainly an area that we want to continue to expand and develop.”

Students at The Ohio State University College of Dentistry in their Periodontal Therapies course practice the placement of an evidence-based, local delivery chemotherapeutic agent for the management of periodontal maintenance patients.

She said she hopes before and after clinic, full-circle communication and collaboration between dental and dental hygiene students will happen when the college finishes its new building in the fall of 2021, which will include eight “small group practices” that will facilitate a more dental office-like feel.

“I think the goal is 15 D3 and 15 D4 students plus four dental hygiene students in each clinic, leading to 34 providers in each of our eight group practice clinics,” she said. “It’s much easier to get to know and collaborate among 34 people in a well-defined space then roughly 70 to 80 groups of people in two massive clinic spaces, as in our old building.”

Learning While Having Fun

Some schools hope to encourage more education and collaboration across the allied dental disciplines. Ozarks Technical Community College (OTC) tries to facilitate this through not only its coursework, but also through fun, team-building activities.

At OTC, dental assisting and dental hygiene students take four of the same courses: Dental Materials, Dental Radiology I, Dental Radiology II and Infection Prevention.

Janet Sell, Ed.D., Program Director of Dental Assisting Program at OTC, said that in addition to these being course requirements for graduation, both sets of students take these classes for two other important reasons. One is that dental hygiene students who have already completed an accredited dental assisting program, which would include these courses, don’t have to retake the courses for graduation, which makes their course loads a little easier.

At Ozarks Technical Community College, dental assisting and dental hygiene students not only take some courses together, but also mentor one another.

“Another advantage is both cohorts—assisting and hygiene—are interactive with each other in the classroom and labs. I believe this will lead to a strong work environment,” Dr. Sell said. “They understand some of the coursework each has to do to be successful in their given programs. It also shows how similar they are in the profession.” She said that even though they have different jobs in the dental offices, taking courses together enables the students to see that it is still “a team effort.”

On the clinical side, Dr. Sell said dental assisting students spend their first clinical days in the second-year dental hygiene clinic.

In addition to having some classes and clinics together, OTC facilitates camaraderie between the disciplines by having dental hygiene students mentor dental assisting students.

“We admit four cohorts—approximately 90 students—two hygiene and two assisting that start at different semesters,” Dr. Sell said. “It is easy to assign senior students to a new student by the way we admit them.”

OTC then mixes up the dental assisting and dental hygiene students and makes them work together on projects. “An example would be the Chili Cookoff to raise money for the dental mission trip to Nicaragua,” Dr. Sell said. The mentors/mentees also continued to work together while on the mission trip. “I believe all the students take away a new friendship and respect for each other’s position,” she said.

Every year, students also participate in the Leadership Ranch for a half day at the beginning of their first semester. “It is an outdoor challenge course that builds teamwork and respect,” Dr. Sell said. “In the past, we have a numerous picnics and have planned team-building activities. We have had an Amazing Race, teaming the assisting and hygiene students together, and incorporated the entire campus.”

Though the COVID-19 pandemic has stopped some or most of the college’s intraprofessional activities, Dr. Sell said OTC hopes to resume these activities in fall 2021 or no later than spring 2022.

Preparing Students for Real-world Challenges

In addition to encouraging intraprofessional education, OTC dental program also conducts interprofessional exercises with other schools within the college. Dr. Sell said OTC offers continuing education seminars, one of which is a simulation (SIM) lab that includes dental assisting, dental hygiene, EMS and nursing students. Four to five “dental teams” work through emergency scenarios that could happen in a real dental practice.

“For example, a patient has a heart attack in the dental chair,” Dr. Sell said. “The dental team understands their responsibilities on who is calling 911, who stays with the patient and who starts CPR. When we do these scenarios in the SIM lab, the dental team and students actually work with a paramedic. Our students have access to the SIM lab and go through medical emergencies every semester.”

Ozarks Technical Community College offers a simulation (SIM) lab that includes dental assisting, dental hygiene, EMS and nursing students. Four to five “dental teams” work through emergency scenarios that could happen in a real dental practice.

The UT Health San Antonio School of Dentistry (UT Health SA SOD) implemented a new interprofessional project starting in 2019 to help dental students deal with real-life, work-related scenarios. The project focuses on ways dental students can reduce the chances of developing musculoskeletal disorders as dental professionals. Though UT Health SA SOD had been incorporating ergonomics into its curriculum for almost 15 years prior to starting this project, SOD decided to reach out to the School of Health Profession’s Occupational Therapy and Physical Therapy programs for more collaboration.

Juanita Lozano-Pineda, D.D.S., M.P.H., Associate Dean for External Affairs and Associate Professor in the Department of Comprehensive Dentistry at UT Health SA SOD, said there were many catalysts for this project.

“We revised our DS1 and DS2 curriculum just before implementing the IPE experience with Occupational Therapy. Prior to the change, I presented only didactic information about the etiology of musculoskeletal disorders, how they impacted dental professionals and how to prevent these,” Dr. Lozano-Pineda said. Also, the new curriculum at SOD “included blocks of rotations within the ‘Introduction to Patient Care (IPC)’ module/track. DS1 and DS2 students are scheduled in smaller groups for these rotations that occur simultaneously but have one group doing ergonomics while another is doing CPR, another introduction to AxiUm, etc., as an example.”

Dr. Lozano-Pineda added that in 2018, the UT Health Science Center chose to have Linking Interprofessional Networks for Collaboration (LINC) as their Southern Association of Colleges and Schools accreditation Quality Enhancement Plan.

“A component of the plan included awarding LINC Seed grants to help the schools collaborate and start IPE activities,” she said.

And finally, in 2019, the School of Health Professions moved their training programs to the same building where the DS1 and DS2 preclinical courses take place. “The proximity of the programs is what had me think of having the Ergonomics training include Physical Therapy experiential learning added to the IPC module. I then approached the faculty about applying for a Seed grant,” Dr. Lozano-Pineda said.

Now, because of that grant, they have an occupational therapy faculty member come in and discuss prevention of musculoskeletal disorders from an ergonomic perspective, encouraging dental students to make sure their clinic environments fit their needs. It may require students to reset equipment in dental clinics, considering layout and lighting, using loops and ensuring their assistants are helping properly. Students are also encouraged to consider their sitting posture and the positioning of the client’s chair.

UT Health SA SOD had physical therapy students conduct muscular therapy evaluations of dental students as well during physical therapy labs. The physical therapy students gave them full treatment sessions, reviewing whatever issues they encountered. Both sets of students responded positively to the evaluations.

To get the project up and running, dental, occupational therapy and physical therapy faculty “met and looked at our individual curriculums and when each student group was learning about ergonomics,” Dr. Lozano-Pineda said. “We then laid out a timeline in which we could cover some components in the fall and others in the spring. The DS1 have their IPC rotations throughout the year. The first year was a bit tougher, as we were trying to get it all in, despite what was already planned academically for each school. This past year, we were able to plan ahead and improve the schedules,” she said.

Learning From Successes

To implement a similar interprofessional project, dental schools should “fit in increments, adding one additional profession first, then another,” Dr. Lozano-Pineda said. “This will allow the phasing in and modifications to the schedules, and planning for the additional profession to modify their curriculum to match what would work once all were interacting.”

She said this is what UT Health SA SOD did, “since we had already included occupational therapy with DS1. Once we opted to do the LINC IPE project, we then added the physical therapy experiential rotation with DS and the occupational therapy observation of DS3. The DS3 had already had the occupational therapy training as DS1 when that was the only other profession I was working with. Therefore, following up with a clinic observation to see if they were implementing what had been taught made sense to us,” Dr. Lozano-Pineda said.

Prof. Henderson said new physical space is crucial to making the shift from massive clinics to more of a small dental office-like feel, which helps to facilitate more collaboration between dental hygiene and dental students.

Even if other dental schools are unable to do this, Prof. Henderson said communication between departments from the beginning of the process is critical to successful collaboration.

“It can’t be the dental hygiene program plans this integrated clinic and then comes to the predoc and says, ‘Hey, do you want to do this with us?’ and then vice versa, you can’t see a predoctoral faculty member just planning this whole thing and coming to the dental hygiene program and saying, ‘Hey do you want to do this thing?’” she said. “I think it has to be done together when you’re like, ‘Hey, we work together. We collaborate together in practice. Would you be interested in working with me to create a plan for how we can work together in a new clinic space?’”

Moving Past the Surface Level

In 2017, the Center for Integration of Primary Care and Oral Health (CIPCOH) conducted a study that showed a large majority of dental schools were participating in interprofessional education (IPE)—more than 15 other health care professions. This is largely the result of Commission on Dental Accreditation (CODA) standards. CODA Dental Hygiene Standard 2-15 and Predoctoral Dental Standard 2-20 emphasize that graduates from academic dental institutions and dental hygiene programs meet competencies in effective communication, understand the social determinants of health and collaborate with other members of the health care sector in the provision and support of patient oral care.

However, the CIPCOH study also found that even though dental education seemed to be achieving its goals of integrating IPE into curricula, it was only doing so on face value, said Christine Riedy, Ph.D., M.P.H., Chair and Associate Professor of Oral Health Policy and Epidemiology at Harvard School of Dental Medicine (HSDM) and Principal Investigator at CIPCOH. She made her comments at the 2021 ADEA Annual Session & Exhibition during the ADEA Chair of the Board Symposium titled A Two-way Street: Primary Care and Oral Health Integration Training. Most deans felt that students weren’t actually ready to collaborate, Dr. Riedy said.

In 2019, CIPOCH further analyzed IPE in dental schools by conducting a study of how primary care aspects are incorporated into Advanced Education in General Dentistry (AEGD) and General Practice Residency (GPR) programs. Tien Jiang, D.M.D., M.Ed., an Instructor of Oral Health Policy and Epidemiology at HSDM and Investigator at CIPCOH, said the study found that AEGD and GPR instructors considered it important to include information such as chronic medical conditions, behavioral health and social determinants of health in curricula, but the challenge was finding the time to include it.

“One dentist told us, ‘You know, how am I supposed to teach about social determinants of health when in that same hour, I have to teach students how to do a better root canal?’” Dr. Jiang said. “So, it’s almost a this or this. Rather than a this and this. And I know that is just semantics, but I understand that for someone who is running a program that sometimes it comes down to the real decision of how do I replace this one thing? How do I teach something all in one year?”

Dr. Jiang noted that the study also showed there is a small but vocal group of faculty members who believe this subject matter has no place in dental education.

“Even though there was really only a handful, there were some program directors who actually felt strongly, for example, that social determinants of health did not have a place in the dental programs,” she said. “And while its good news that the majority feel strongly about including these aspects of health, it’s still concerning that we have a small number that do not feel it is important.”

Making Hard but Rewarding Decisions

For those who do believe it is important, she said hard decisions must be made about what goes and what stays in curricula to accommodate this widening breadth of learning.

“I think the COVID-19 pandemic really addressed this need to snip out and trim the fat in a lot of our curricula and say this is addressing the standards of competencies that the students have to graduate with,” Dr. Jiang said. “… I think right now is a great time for schools to really see and evolve the curricula that’s been in place for decades and cut out curricula that maybe can be better done online and value the time in person for something like an IPE.”

And schools don’t have to make all the tough decisions on their own, she said. “I think schools are very proud about creating their own curricula, but we’re doing a better job now sharing curricula across different platforms,” Dr. Jiang said. “I mean, it takes a lot of time and effort, but if there’s already a toolkit or guide out there, we really need to do a better job at being willing to share that.”

Once schools decide what direction they wish to go, collaboration remains important to get the ball rolling and keep up the momentum.

“I’ve been in a conversation with a predoc faculty member about opportunities for collaboration—whether clinical or curricula change or didactic change—there’s always lots of ideas,” Prof. Henderson said. “You know sometimes it’s a fearful idea. ‘We’ve never done that before. I can’t imagine how we could do that’ and other times it’s, ‘Oh, my gosh! That sounds really fun! Let’s work together and figure out how we can,’ and other times it’s, ‘I wonder how we would be allowed to do that.’ Any time you’re considering a big change, there’s all those kinds of normal feelings of uncertainty, questioning and fear, but it’s also a lot of excitement too and opportunity.”

And the students will ultimately benefit in the end from inter- and intraprofessional education. “I believe strongly the students who learn together will be better employees, will work as team players,” Dr. Sell said. “Or, even better, will continue their education and have respect for each other’s occupations.”

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