words by Merry Sue Baum / photographs by Pete Byron
he patient in the first operatory, Mrs. Smith, has a headache. Her physician was unable to determine the cause, so she has come to the dentist. In a few minutes, the dentist will come in and talk with her about her problem and suggest a treatment. When her appointment is over, however, Mrs. Smith won’t gather her things and leave; she’ll stay in the chair and discuss her problem with other dentists, over and over again.
That exact scenario takes place every fall at UMDNJ-New Jersey Dental School (NJDS) in Newark. Mrs. Smith is not an actual patient, and the dentists are third-year (junior) students participating in a training program known as Clinical Communications 1 (CC1). The program was developed and implemented in 1995 by Hillary Broder, PhD, MEd, a professor in the NJDS Department of Community Health, and is one of only three dental programs of its kind in the country. It aims to enhance students’ cultural competence and to teach them to build rapport with their patients. “As dental educators, we strive to prepare students to treat the whole patient,” says Broder. “We believe effective treatment targets not only patients’ objective clinical needs but also their subjective or perceived needs. Their sociocultural and psychological issues are vital to effective treatments.”
The “patients” in the scenarios are people trained to simulate a dental condition in a standardized fashion. Because these performers also function as teachers and evaluators, they are known as patient instructors, or PIs. Before becoming a PI, they must complete nine hours of training, learning to rate the students using the Arizona Clinical Interviewing Rating Scale, a tool that is widely applied in health settings to evaluate interpersonal interviewing skills. They then practice six different patient scenarios and are coached on how to give students positive feedback and constructive criticism. Finally, they practice their scenarios by role-playing with three NJDS faculty. PIs who return the next year are recalibrated, using videotapes of role-playing sessions.
|Hillary Broder, PhD, MEd|
NJDS PIs are mostly actors and retired teachers. They never have procedures performed on their teeth or even have their blood pressures taken. They simply discuss a chief complaint and portray whatever emotions the script demands, like fear, anxiety or depression. The scenarios deal with relatively straightforward dental problems and personal psychosocial issues. For example, Mrs. Smith — whose chief complaint is TMD — has had a number of negative experiences with dentists and is very anxious. During her encounter with the student, she continually flaps her hands in her lap and shakes her foot, nonstop. She also mentions, over and over, that she’s very nervous. Another scenario involves a very demanding woman who has poorly fitting dentures, and a war veteran has dental pain, but is worried about how he will pay the bill.
The PIs are paid $20 an hour, however, most say they would participate without getting a paycheck. Veteran PI, Zella Geltman, a retired English teacher who taught at Montclair State University, believes the program is vital to training top-notch dentists. “Learning the human side of medicine and integrating it into the technical side is what it’s all about,” she says. “It’s the little things, like direct eye contact and shaking the patient’s hand, that make all the difference. As a PI, I’m helping students enhance their skills, which is very rewarding. And it’s fun, too.”
On “test day,” four students have interviews, or patient encounters, with four different PIs, for 15 minutes each. Before the interview begins, the students review the chart and begin by establishing a rapport with the patient. They take a medical, dental and psychosocial history and zero in on the patient’s chief complaint. Finally, they discuss a brief treatment plan. The students are timed, and get a five-minute warning.
When the encounter is over, the PIs spend about 15 minutes giving each student feedback. “By getting immediate feedback from the PIs, the students can improve their data gathering skills and interviewing skills right away,” says Broder. “We see significant improvement as they go from their first patient to their last.” At the end of the day, the course director debriefs the PIs on the students’ performances, and later meets with the students to discuss the outcomes. Those students with weaker scores have a chance to improve by completing another interview session or attending a seminar on taking patient histories.
Since one third of the U.S. population is from racial and ethnic minorities — and experts predict that trend will continue — Broder developed a second PI program, known as Clinical Communication 2. It is administered in the spring of the students’ third (junior) year, nine months after CC1 and after they have been seeing actual patients. CC2 PIs have more challenging personalities and more complex histories and dental problems. One example is a patient with periodontal disease who believes she is having a problem because the gods are angry with her. Another patient presents with xerostomia and has a history of prostate cancer and depression. Other scenarios include a woman who has an oral/facial injury and has an abusive husband; a patient who is inebriated and has dental pain; an individual with obsessive-compulsive disorder and a cough who has a non-specific complaint; and a patient with osteogenic sarcoma that is complicated by her traditional Muslim beliefs.
Broder has completed studies on the program, and all show that students’ data collecting and interpersonal skills improve significantly as a result of the training. The students, themselves, report that they find the program extremely valuable, and getting feedback immediately after each encounter, rather than after all the encounters are completed, is very effective. Some have even suggested that they be required to go through more sessions and several suggested that a continuing education program be created for practicing dentists.
While the tried-and-true method of reading and writing are still as valuable as ever, dental students and professors agree that there’s nothing like the real thing. Or in this case, almost the real thing.