An Undergraduate Program in Anesthesia and Medicine:
Five Years Later Stanley F. Malamed, D. D. S.tt Thomas J. Pallasch, D. D. S., M. S.ttt Frank M. McCarthy, M. D., D. D. S.tttt In 1973 the University of Southern California, School of Dentistry initiated a pilot program in the Management of Pain and Anxiety. The goal of this program was to assess the most effective manner to incorporate it into a dental curriculum. Support for this program was provided through a special project grant in clinical pharmacology of the National Institutes of Health'. Impressions from this pilot program2 are summarized as follows: (a) The concept embodied in the Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry3 is too broad to be effectively taught in one course. The pilot program was therefore directed at a single area: the management of anxiety, with primary emphasis on the oral, inhalation and intravenous routes of administration; (b) introduction of these techniques of psychosedation to fourth year dental students did not permit adequate experience to develop clinical proficiency before graduation and; (c) students employing these techniques must be monitored by well trained faculty members. This is of especial importance during intravenous sedation. Five years have elapsed since the pilot program, with twenty fourth year dental students, was inaugurated. Significant changes in the undergraduate curriculum in the area of anesthesia and medicine have occurred since this time, as a result of this pilot program. The results of this five year evolution of a highly successful program are presented. It is hoped that our experiences at U. S. C. in this area may serve to benefit other programs being developed at this time. Since the pilot program in 1973 the Section of Anesthesia and Medicine has been established. This section has the responsibility of teaching all undergraduate dental, dental hygiene and international dental students, as well as post-graduate students all courses relating to the following four areas: psychosedation (anxiety control), local anesthesia (pain control), tUniversity of Southern California School of Dentistry 925 West 34th Street Los Angeles, California 90007 ttAssistant Professor of Anesthesia and Medicine t Associate Professor and Chairman, Department of
Pharmacology
'ttttProfessor and Chairman, Anesthesia and Medicine
188
emergency medicine, and physical evaluation. The primary emphasis of this communication will be on the evolution of the anxiety control program. The other areas of responsibility will be discussed briefly at this time.
Psychosedation Our original concept of the psychosedation program was to maintain it as an elective program, thereby attracting only the more highly motivated student. Response to the program was such, however, that in excess of 85% of our dental students enrolled in the course when it was offered as an elective to second year students. Because of this response the undergraduate training program in psychosedation was added to the curriculum as a requirement in November 1974. The program, as currently presented, encompasses two fourteen week periods of the second year. The first trimester introduces all students to the problem of anxiety and its recognition, basic concepts of
psychosedation, and in-depth discussions of the oral, intramuscular and inhalation routes of psychosedation. Each student is involved in two clinical laboratory sessions during which they are trained in the clinical use of inhalation sedation with nitrous oxide and oxygen. The second clinical session is a practical examination in which the student must successfully administer N20-02 to a student-patient. Following successful completion of this program, students are permitted to utilize N20-02 inhalation sedation on clinic patients during dental therapy. The undergraduate dental student has two full years of experience remaining during which time a requirement of at least 5 clinical cases with N20-02 must be fulfilled. The following trimester, the dental student and international student is enrolled in the second part of the program in psychosedation. Emphasis in this program is on the technique of venipuncture and on the various techniques of intravenous sedation. A brief discussion is directed at general anesthesia at the end of this program. Two laboratory sessions permit the student to become capable of successfully completing a venipuncture. Following this program the student has a requirement of three intravenous sedation procedures prior to graduation. ANESTHESIA PROGRESS
Until early 1977 these requirements in both inhalation and intravenous sedation were but loosely adhered to. Several reasons are offered as an explanation: Students entering the general clinic were acting as the "pathfinders" in the use of these procedures. Prior to 1973, sedation, especially intravenous sedation, had been employed almost exclusively in the oral surgery clinics. Students were reluctant to use these techniques in other clinical areas of the School. This inertia also involved some reluctance on the part of some full and part-time faculty members to accept these techniques. Peer pressure on dental students made them even more reticent to employ these techniques. A paucity of well-trained faculty to aid in monitoring students on the clinic floor with these techniques contributed to its slow acceptance. The increase -in the number of inhalation sedation procedures and to a lesser extent, intravenous sedation procedures during the past four years (Table 1) may be attributed to the following: (a) The use of these techniques in the many clinical areas ofthe School is no longer a rarity. Indeed the use of inhalation sedation is commonplace. Students no longer are reluctant to offer this technique to their anxious dental patients. (b) Faculty attitudes regarding the techniques of psychosedation have altered. Through a combination of faculty in-service training programs in psychosedation as well as their first-hand clinical observation of these techniques being employed by dental students on patients, faculty members are now more aware of the benefits to be gained from these procedures. (c) With the increased enthusiasm & knowledge by dental faculty in these techniques, especially N20-02, monitoring ofstudents no longer requires a member of the Section of Anesthesia and Medicine to be physically present. Trained faculty in all dental disciplines, are now available throughout the school to assist & supervise inhalation sedation. A faculty member from the Section of Anesthesia and Medicine is always available via beeper-page should additional assistance be required. The increase in the number of cases on inhalation sedation seen over the past few years is directly attributable to these factors. Because of this, student requirements in inhalation sedation are strictly adhered to at this time. Intravenous sedation has also undergone an increase in utilization over the past few years, but not to the same degree as has nitrous oxide and oxygen inhalation sedation. Direct supervision of student-doctors by a well trained faculty member is a strict requirement, and until recently only two such faculty members were available. Early in 1978 part-time volunteer faculty wre enlisted by the Section of Anesthesia and Medicine. Qualifications for this position includes advanced training or expertise in either anesthesia (psychosedation, general anesthesia) and/or physical evaluation. Those faculty members with expertise in anesthesia are assigned to monitor intravenous and inhalation sedation procedures on the clinic floor. Since entry of our part-time faculty into the clinics in NOVEMBER - DECEMBER, 1978
May 1978, the number of intravenous procedures completed has increased markedly. Today, the dental graduate from the University of Southern California is well equipped to safely and effectively manage both the apprehensive dental patient and the medical risk dental patient, through a knowledge of various procedures of stress-reduction4, including the ability to administer oral, intramascular, inhalation and intravenous sedation. Emergency Medicine Emergency medicine was originally included as a small section of the pilot program in psychosedation. However, because of student and faculty demands for further training in this subject, a separate program was established. Today, all students receive a 14 hour didactic program in emergency medicine. This occurs during the first year of the dental hygiene and international students program, and during the second year of the dental student program. Laboratory sessions lead to certification in basic cardiac life support, including practice in management of the obstructed airway. In all cases students complete the program of training in emergency medicine prior to their introduction to the clinical management of dental patients. Proficiency in this important area is maintained by periodic, unscheduled mock-emergency situations which are called on the clinic floor (i.e. cardiac arrest, anaphylactic shock), requiring student participation. Local Anesthesia The teaching of local anesthesia to students at U. S. C. predated the introduction of the psychosedation program and the establishment of the Section of Anesthesia and Medicine. Now this program includes 14-16 hours of didactic and 4-6 hours of supervised clinical experience. Both dental and dental hygiene students receive the program in the latter parts of their first year. This program will be described more completely in a later communication5.
Physical Evaluation In 1977 the undergraduate curriculum introduced several courses in physical evaluation. These programs are required for all dental, dental hygiene and international students and are presented in the second year of training for dental studqnts, the first year for other students. The stated goal of the introductory program in physical evaluation, a 28 hour didactic course over two trimesters, is to enable the student to understand selected aspects of internal medicine, physical evaluation and emergency medicine, as they apply to the practice of dentistry. Lecture and clinical sessions are devoted to heart and lung auscultation. Following completion of the introductory program students are assigned to interdisciplinary health team program where a medically compromised patient receives a thorough physical evaluation as a part of the screening process prior to acceptance as a patient at the school of 189
dentistry. The dental student, acting as the team leader, attends three health team sessions over the next three trimesters. Other members of the team include: an optometry student, responsible for visual assessment; a health education student, responsible for the psychosocial history; a dental hygiene student, responsible for nutritional assessment; and a pharmacist, seeking the patients drug history. The dental student is responsible for obtaining the patients medical history and a complete physical examination (from the waist up) of the prospective patient. The health team is under the overall supervision of a member of the section on Anesthesia and Medicine, trained in all aspects of physical evaluation. Senior Seminar In the fourth year, senior dental students attend one seminar session designed to recapitulate the highlights of their education in the areas of anesthesia and medicine, and to integrate this material so that the student will be better able to incorporate these principles into the practice of dentistry.
Summary During the past five years the undergraduate training program in anesthesia and medicine at the University of Southern California School of Dentistry has been greatly expanded. Today this section is responsible for providing all undergraduate students with education in psychosedation, local anesthesia, emergency medicine, and physical evaluation. Upon graduation students can be expected to be proficient in the administration of local anesthesia, oral, inhalation and intravenous sedation, and to be adept in physical evalua-
tion, including heart and lung auscultation, and, the recognition and management of acute medical emergencies, including the capability of performing basic cardiac life support measures. TABLE 1 Summary of Psychosedation Procedures
year 1975 1976 1977 1978 (6
INHALATION INTRAVENOUS SEDATION SEDATION general pedogeneral pedoclinics dontics total* clinics dontics total* 195 83 278 18 0 18 303 111 414 38 5 43 560 157 717 67 11 78
months) 525 146 671 55 9 64 * totals do not include N20-02 and intravenous procedures within the oral surgery clinics REFERENCES 1. Special project grant in clinical pharmacology. no. 5CO8PEO 1198-02, National Institutes of Health, Bethesda Maryland. 2. Malamed S F Pallasch T J U. S.C. School of Dentistry-guidelines for the control of pain and anxiety. Anesth Prog 21:4 99, 1974. 3. Guidelines for teaching the comprehensive control of pain and anxiety in dentistry. J Dent Educ 36:62, 1972. 4. Malamed S F Stress-reduction protocols (Submitted for publication J Am Dent Assoc.) 5. Malamed S F A curriculum in local anesthesia (Submitted for publication J Dent Educ.)
ANNOUNCEMENT (
Five Years Later Stanley F. Malamed, D. D. S.tt Thomas J. Pallasch, D. D. S., M. S.ttt Frank M. McCarthy, M. D., D. D. S.tttt In 1973 the University of Southern California, School of Dentistry initiated a pilot program in the Management of Pain and Anxiety. The goal of this program was to assess the most effective manner to incorporate it into a dental curriculum. Support for this program was provided through a special project grant in clinical pharmacology of the National Institutes of Health'. Impressions from this pilot program2 are summarized as follows: (a) The concept embodied in the Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry3 is too broad to be effectively taught in one course. The pilot program was therefore directed at a single area: the management of anxiety, with primary emphasis on the oral, inhalation and intravenous routes of administration; (b) introduction of these techniques of psychosedation to fourth year dental students did not permit adequate experience to develop clinical proficiency before graduation and; (c) students employing these techniques must be monitored by well trained faculty members. This is of especial importance during intravenous sedation. Five years have elapsed since the pilot program, with twenty fourth year dental students, was inaugurated. Significant changes in the undergraduate curriculum in the area of anesthesia and medicine have occurred since this time, as a result of this pilot program. The results of this five year evolution of a highly successful program are presented. It is hoped that our experiences at U. S. C. in this area may serve to benefit other programs being developed at this time. Since the pilot program in 1973 the Section of Anesthesia and Medicine has been established. This section has the responsibility of teaching all undergraduate dental, dental hygiene and international dental students, as well as post-graduate students all courses relating to the following four areas: psychosedation (anxiety control), local anesthesia (pain control), tUniversity of Southern California School of Dentistry 925 West 34th Street Los Angeles, California 90007 ttAssistant Professor of Anesthesia and Medicine t Associate Professor and Chairman, Department of
Pharmacology
'ttttProfessor and Chairman, Anesthesia and Medicine
188
emergency medicine, and physical evaluation. The primary emphasis of this communication will be on the evolution of the anxiety control program. The other areas of responsibility will be discussed briefly at this time.
Psychosedation Our original concept of the psychosedation program was to maintain it as an elective program, thereby attracting only the more highly motivated student. Response to the program was such, however, that in excess of 85% of our dental students enrolled in the course when it was offered as an elective to second year students. Because of this response the undergraduate training program in psychosedation was added to the curriculum as a requirement in November 1974. The program, as currently presented, encompasses two fourteen week periods of the second year. The first trimester introduces all students to the problem of anxiety and its recognition, basic concepts of
psychosedation, and in-depth discussions of the oral, intramuscular and inhalation routes of psychosedation. Each student is involved in two clinical laboratory sessions during which they are trained in the clinical use of inhalation sedation with nitrous oxide and oxygen. The second clinical session is a practical examination in which the student must successfully administer N20-02 to a student-patient. Following successful completion of this program, students are permitted to utilize N20-02 inhalation sedation on clinic patients during dental therapy. The undergraduate dental student has two full years of experience remaining during which time a requirement of at least 5 clinical cases with N20-02 must be fulfilled. The following trimester, the dental student and international student is enrolled in the second part of the program in psychosedation. Emphasis in this program is on the technique of venipuncture and on the various techniques of intravenous sedation. A brief discussion is directed at general anesthesia at the end of this program. Two laboratory sessions permit the student to become capable of successfully completing a venipuncture. Following this program the student has a requirement of three intravenous sedation procedures prior to graduation. ANESTHESIA PROGRESS
Until early 1977 these requirements in both inhalation and intravenous sedation were but loosely adhered to. Several reasons are offered as an explanation: Students entering the general clinic were acting as the "pathfinders" in the use of these procedures. Prior to 1973, sedation, especially intravenous sedation, had been employed almost exclusively in the oral surgery clinics. Students were reluctant to use these techniques in other clinical areas of the School. This inertia also involved some reluctance on the part of some full and part-time faculty members to accept these techniques. Peer pressure on dental students made them even more reticent to employ these techniques. A paucity of well-trained faculty to aid in monitoring students on the clinic floor with these techniques contributed to its slow acceptance. The increase -in the number of inhalation sedation procedures and to a lesser extent, intravenous sedation procedures during the past four years (Table 1) may be attributed to the following: (a) The use of these techniques in the many clinical areas ofthe School is no longer a rarity. Indeed the use of inhalation sedation is commonplace. Students no longer are reluctant to offer this technique to their anxious dental patients. (b) Faculty attitudes regarding the techniques of psychosedation have altered. Through a combination of faculty in-service training programs in psychosedation as well as their first-hand clinical observation of these techniques being employed by dental students on patients, faculty members are now more aware of the benefits to be gained from these procedures. (c) With the increased enthusiasm & knowledge by dental faculty in these techniques, especially N20-02, monitoring ofstudents no longer requires a member of the Section of Anesthesia and Medicine to be physically present. Trained faculty in all dental disciplines, are now available throughout the school to assist & supervise inhalation sedation. A faculty member from the Section of Anesthesia and Medicine is always available via beeper-page should additional assistance be required. The increase in the number of cases on inhalation sedation seen over the past few years is directly attributable to these factors. Because of this, student requirements in inhalation sedation are strictly adhered to at this time. Intravenous sedation has also undergone an increase in utilization over the past few years, but not to the same degree as has nitrous oxide and oxygen inhalation sedation. Direct supervision of student-doctors by a well trained faculty member is a strict requirement, and until recently only two such faculty members were available. Early in 1978 part-time volunteer faculty wre enlisted by the Section of Anesthesia and Medicine. Qualifications for this position includes advanced training or expertise in either anesthesia (psychosedation, general anesthesia) and/or physical evaluation. Those faculty members with expertise in anesthesia are assigned to monitor intravenous and inhalation sedation procedures on the clinic floor. Since entry of our part-time faculty into the clinics in NOVEMBER - DECEMBER, 1978
May 1978, the number of intravenous procedures completed has increased markedly. Today, the dental graduate from the University of Southern California is well equipped to safely and effectively manage both the apprehensive dental patient and the medical risk dental patient, through a knowledge of various procedures of stress-reduction4, including the ability to administer oral, intramascular, inhalation and intravenous sedation. Emergency Medicine Emergency medicine was originally included as a small section of the pilot program in psychosedation. However, because of student and faculty demands for further training in this subject, a separate program was established. Today, all students receive a 14 hour didactic program in emergency medicine. This occurs during the first year of the dental hygiene and international students program, and during the second year of the dental student program. Laboratory sessions lead to certification in basic cardiac life support, including practice in management of the obstructed airway. In all cases students complete the program of training in emergency medicine prior to their introduction to the clinical management of dental patients. Proficiency in this important area is maintained by periodic, unscheduled mock-emergency situations which are called on the clinic floor (i.e. cardiac arrest, anaphylactic shock), requiring student participation. Local Anesthesia The teaching of local anesthesia to students at U. S. C. predated the introduction of the psychosedation program and the establishment of the Section of Anesthesia and Medicine. Now this program includes 14-16 hours of didactic and 4-6 hours of supervised clinical experience. Both dental and dental hygiene students receive the program in the latter parts of their first year. This program will be described more completely in a later communication5.
Physical Evaluation In 1977 the undergraduate curriculum introduced several courses in physical evaluation. These programs are required for all dental, dental hygiene and international students and are presented in the second year of training for dental studqnts, the first year for other students. The stated goal of the introductory program in physical evaluation, a 28 hour didactic course over two trimesters, is to enable the student to understand selected aspects of internal medicine, physical evaluation and emergency medicine, as they apply to the practice of dentistry. Lecture and clinical sessions are devoted to heart and lung auscultation. Following completion of the introductory program students are assigned to interdisciplinary health team program where a medically compromised patient receives a thorough physical evaluation as a part of the screening process prior to acceptance as a patient at the school of 189
dentistry. The dental student, acting as the team leader, attends three health team sessions over the next three trimesters. Other members of the team include: an optometry student, responsible for visual assessment; a health education student, responsible for the psychosocial history; a dental hygiene student, responsible for nutritional assessment; and a pharmacist, seeking the patients drug history. The dental student is responsible for obtaining the patients medical history and a complete physical examination (from the waist up) of the prospective patient. The health team is under the overall supervision of a member of the section on Anesthesia and Medicine, trained in all aspects of physical evaluation. Senior Seminar In the fourth year, senior dental students attend one seminar session designed to recapitulate the highlights of their education in the areas of anesthesia and medicine, and to integrate this material so that the student will be better able to incorporate these principles into the practice of dentistry.
Summary During the past five years the undergraduate training program in anesthesia and medicine at the University of Southern California School of Dentistry has been greatly expanded. Today this section is responsible for providing all undergraduate students with education in psychosedation, local anesthesia, emergency medicine, and physical evaluation. Upon graduation students can be expected to be proficient in the administration of local anesthesia, oral, inhalation and intravenous sedation, and to be adept in physical evalua-
tion, including heart and lung auscultation, and, the recognition and management of acute medical emergencies, including the capability of performing basic cardiac life support measures. TABLE 1 Summary of Psychosedation Procedures
year 1975 1976 1977 1978 (6
INHALATION INTRAVENOUS SEDATION SEDATION general pedogeneral pedoclinics dontics total* clinics dontics total* 195 83 278 18 0 18 303 111 414 38 5 43 560 157 717 67 11 78
months) 525 146 671 55 9 64 * totals do not include N20-02 and intravenous procedures within the oral surgery clinics REFERENCES 1. Special project grant in clinical pharmacology. no. 5CO8PEO 1198-02, National Institutes of Health, Bethesda Maryland. 2. Malamed S F Pallasch T J U. S.C. School of Dentistry-guidelines for the control of pain and anxiety. Anesth Prog 21:4 99, 1974. 3. Guidelines for teaching the comprehensive control of pain and anxiety in dentistry. J Dent Educ 36:62, 1972. 4. Malamed S F Stress-reduction protocols (Submitted for publication J Am Dent Assoc.) 5. Malamed S F A curriculum in local anesthesia (Submitted for publication J Dent Educ.)
ANNOUNCEMENT (
