BRIEF REPORT
Introduction of an Interprofessional Oral Health Curriculum Oren Berkowitz, PhD, MSPH, PA-C, Laura B. Kaufman, DMD, Matthew Russell, MD, MSc Purpose Physician assistants can incorporate a variety of oral health services into their practices, but many physician assistant programs do not dedicate adequate time to oral health education. Our goal was to develop a novel and interprofessional oral health education curriculum model for our physician assistant students that could be adopted by other physician assistant programs and dental schools in the United States. Methods Curricula were created collaboratively and taught by dental school faculty with a focus on the primary care setting. Prewritten and postwritten tests were administered along with a clinical skills examination. Student and faculty evaluations were administered for pedagogical evaluation.
Feature Editor’s Note: Physician assistant educators are constantly faced with adding curricular content to stay abreast of advances in medicine. Measuring the effectiveness of newly developed instructional content is necessary to assure that actual student learning occurs. This article describes the integration of a new oral health component into an existing curriculum (planned as a 2-phase implementation) and offers a model for assessing outcomes of the initial offering. Faculty and student evaluations of the instructional delivery combined with measures of cognitive performance (pre/ posttests and a later final examination) give direction for future curricular enhancements. For the topic of oral health, this model demonstrating interprofessional instruction with PAs and dentists is likely a key to success. Michael Huckabee, PhD, MPAS, PA-C
Results Pretests and posttests demonstrated a 25% increase in knowledge acquisition (paired t test: P < .001). Physical examination skills testing achieved a 95% completion rate. Student and faculty evaluations demonstrated high satisfaction rates with the curricula delivery. Conclusions Initial evaluation of this novel interprofessional curriculum for physician assistant students demonstrates that it was successful. It was well-received by the students and the faculty members and resulted in measurable knowledge acquisition. This model could feasibly be reproduced in other institutions for oral health education.
education, and prophylactic fluoride applications.2,3 PAs can incorporate aspects of oral health in a cost-effective manner and serve a wide variety of patients who otherwise may have little or no access to dental care.4 Many PA programs have little time in the curriculum for the topic of oral health. A recent survey found that close to 75% of PA directors recognized the importance of oral health education for their students, although most believed that a minimum of 5.3 instructional hours was necessary. In contrast to these findings, fewer than 25% of PA programs included any oral health education in their curriculum, with those including oral health education averaging only 3.6 hours.5 The Boston University School of Medicine PA Program (BUSMPAP), together with our colleagues at the Boston University Henry M. Goldman School of Dental Medicine (HMGSDM), developed a novel and interprofessional oral health education curriculum for our PA students. Our aim is to permanently integrate this new and sustainable model into our core curriculum through inclusion in our clinical medicine course. We anticipate that this model could be adopted by other PA programs and dental schools in the United States.
INTRODUCTION As front-line clinicians, physician assistants (PAs) often provide a first line of defense in oral health for their patients.1 Policy advisors report that nondental primary health care providers, such as PAs, can integrate oral health into their routine examinations with oral health screenings, preventive dental
The authors declare no conflict of interest. J Physician Assist Educ 2015;26(1):43–46 Copyright ª 2015 Physician Assistant Education Association DOI 10.1097/JPA.0000000000000014
March 2015 Volume 26 Number 1
METHODS Learning objectives and outcomes were created collaboratively between the BUSMPAP faculty course directors and the HMGSDM faculty lecturers. A 2-part curriculum was developed to take place in the first and last semesters of the didactic year. All lectures and laboratory time are taught by a HMGSDM faculty member. The focus of the oral health curriculum is the primary care setting with competency development in oral health screening, patient education, and the use of appropriate referrals. A 2-hour general introduction to oral health was delivered during the Introduction to Clinical Medicine course in the first 43
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT semester. A 1-hour Overview of Oral Health lecture was followed by a 1-hour oral/dental examination skills session in clinical simulation rooms. The examination skills session was facilitated by 2 HMGSDM core faculty members, a dental fellow, and a dental student. The PA students had the opportunity to learn and practice the oral health screening examination on each other. These sessions took place after the head and neck portion of the Introduction to Clinical Medicine Course to contextualize oral health and teach students how to perform an oral health screening examination. Program Evaluation This newly developed curriculum was evaluated in several ways. The first part was assessed through peer review by BUSMPAP faculty, written student evaluations, multiple-choice examination, and clinical skills examination results. The peer evaluation of the session was performed by 2-core BUSMPAP faculty members who attended the lecture and laboratory sessions. Both the peer evaluation form and the student evaluation form were taken from our existing programmatic evaluation tools used for all courses. The peer evaluation form consisted of 31 items on a Likert scale of 1–5, with the student evaluation also on a Likert scale. A novel demographic questionnaire was developed and administered to the students to quantify the demographic distribution of the class and ascertain any experience in the dental field. A written test was created to assess baseline oral health knowledge and knowledge acquisition from the first oral health didactic session. The test, consisting of 10 multiplechoice questions relating to the learning objectives of the first session, was administered a week before the first session. The same test was administered again after the first session. The examination included questions on basic oral anatomy, professional roles, public health issues, education, and prevention. The students were not permitted to review the test, the answers were not discussed, and the scores were not reported to the students. Oral health items from the clinical skills laboratory were integrated into the Introduction to Clinical Medicine final examination. This was a comprehensive head-to-toe physical examination test that occurred at the end of the summer semester. The oral health portion included 9 items that related to inspection of extraoral structures, intraoral structures, dentition, and gingiva. Informed consent was obtained from all participants before participation, and this study was exempted as educational research by the Boston University Medical Center Institutional Review Board. This project was
supported by grant funding from the nccPA Health Foundation.
RESULTS All PA students (n = 25) participated in the curriculum and program evaluation. The class comprised 40% males with a median age of 24 years (range, 22–37). None of the students reported ever working clinically in the oral health field. One student reported working as a receptionist in a dental clinic for one year. The learning objectives of the first-hour didactic session included the roles and interactions of PAs and dentists as part of an interprofessional health care team, normal oral anatomic structures, abnormal oral findings, oral and extraoral cancer, common oral health conditions, the public health burden of oral disease, and prevention of oral diseases. The second-hour laboratory session focused on a comprehensive intraoral examination that can be performed in a typical outpatient medical examination room setting. Examination skills included the proper manipulation of the tongue, visual inspection of high-risk cancer areas, and how to use a dental mirror to view hard-to-see areas of the mouth. The faculty peer evaluations of the oral health lecture resulted in an average of 4.77 (5 representing high satisfaction), and the student evaluations of the lecture resulted in a mean score of 4.7. The student evaluations of the laboratory session resulted in an overall mean score of 4.59 across all the 4 laboratory facilitators (range, 4.5–4.62) (Figure 1). The mean score on the pretest written examination was 63% (SD = 13), and the mean score on the posttest was 88% (SD = 9), representing a statistically significant improvement of 25% (paired t test: P < .001) after the session (Figure 2). The clinical skills final examination of the Introduction to Clinical Medicine course resulted in an average score of 95% for the 9 oral health-related items (Table 1).
DISCUSSION Our results show that the introduction of the interprofessional oral health curriculum was well-received by students and faculty. Although our student population had no previous experience in clinical oral health, implementing these curricula resulted in statistically significant knowledge acquisition. Students averaged a 25% increase from baseline on a 10question examination after receiving 2 hours of classroom and laboratory instruction. They also exhibited successful clinical skills acquisition related to the oral examination.
Figure 1. Survey evaluations of classroom and laboratory sessions by students and faculty.
44
Journal of Physician Assistant Education
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT
Figure 2. Written examination pretest and posttest results of students’ general oral health knowledge.
This brief report presents the findings of the first phase of a 2-part curriculum in oral health for our students. A total of 12 hours of oral health education is planned for the curriculum over the next year, well above the reported national PA average of 3.6 hours and exceeding the 5.3 hours recommended by PA program directors.5 Although the curriculum is divided over the course of one year, the vertical integration of oral health is expected to result in long-term retention of oral health knowledge and skills. The general concepts of oral health were introduced early on so that students are comfortable with the basic knowledge. The oral examination skills were taught within a month of the head and neck curriculum, emphasizing the intraoral and extraoral components of the patient physical examination. The general topics will be revisited at the end of the didactic curriculum, at which time new specialty topics will be added. This schedule will provide students with a broader context in preparation for the
Table 1: Oral Examination Skills Test Item Performance (N = 25) Oral Examination Skill
Score (%)
Upper lymph nodes
100
Inspect oral cavity
100
Inspect tongue and floor of mouth
100
Inspect lips, labial/buccal mucosa
96
Inspect teeth
96
Inspect gums
92
Lower lymph nodes
92
Comment on oral hygiene
88
Inspect hard palate and oropharynx
88
March 2015 Volume 26 Number 1
specialty topics that will be discussed toward the end of the didactic year in phase 2. Goals and Direction for the Future One of the main goals of this project is interprofessional collaboration and education. Through this collaboration between BUSMPAP and HMGSDM, both the students and faculty members have benefitted from working and learning together. The students are taught directly by experts in the field of dentistry and have a chance to interact one-on-one with the dental professionals in the skills laboratory. The faculty members are able to learn about each other’s program structures and pedagogical methods. Our collaboration has become visible throughout our institution, and the medical school has expressed an interest in developing oral health educational activities and collaborations for medical students, as well. In the second phase of our curriculum, we will teach specialty topics such as oral health in pregnancy, geriatric oral health, and pediatric oral health. At that time, students will undergo a more rigorous assessment aimed at better evaluating their competencies. A qualitative assessment is planned for the end of the BUSMPAP didactic year to gauge the students’ attitudes toward learning in an interprofessional environment. We will also readminister the same 10-question examination at the end of their didactic year to measure long-term retention.
CONCLUSIONS Oral health is a topic that has been inadequately addressed in PA education. The BUSMPAP and the HMGSDM worked collaboratively to develop an interprofessional curriculum for PA students taught by HMGSDM faculty. As reported here, the first part of the curriculum was successful and could feasibly be reproduced in other institutions. It was well-received 45
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT by the students and the faculty members and resulted in measurable knowledge acquisition. This was the first step in a 2-step curriculum process, which will culminate at the end of the didactic year. The programmatic evaluation will continue with a qualitative assessment of the PA students’ interprofessional learning attitudes and further clinical competency assessments. Oren Berkowitz, PhD, MSPH, PA-C, is Director of Research for the Physician Assistant Program and an Assistant Professor of Medicine at the Boston University School of Medicine. Laura B. Kaufman, DMD, is Clinical Assistant Professor in the Department of General Dentistry of the Boston University Henry M. Goldman School of Dental Medicine and a Clinical Assistant Professor, Section of Geriatrics, in the Department of Medicine at the Boston University School of Medicine. Matthew Russell, MD, MSc, is Medical Director for Hebrew Senior Life Rehabilitation Services. Correspondence should be addressed to: Oren Berkowitz, PhD, MSPH, PA-C, Boston University School of Medicine Physician Assistant Program, 72 E.
46
Concord St. L801 Boston, MA 02118. Telephone (617) 638-5744; Fax 617-638-5204; Email: [email protected]
REFERENCES 1. Institute of Medicine. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011. http://www. hrsa.gov/publichealth/clinical/oralhealth/advancingoralhealth.pdf. Accessed February 6, 2014. 2. Riter D, Maier R, Grossman DC. Delivering preventive oral health services in pediatric primary care: a case study. Health Aff (Millwood). 2008;27(6): 1728–1732. 3. Cantrell C. Engaging Primary Care Medical Providers in Children’s Oral Health. National Academy for State Health Policy; 2009: Portland, ME. 4. Essary AC; Clinical and Scientific Affairs Council of the AAPA. Oral health: caring for primary care patients. JAAPA. 2011;24(5): 27–28. 5. Jacques PF, Snow C, Dowdle M, et al. Oral health curricula in physician assistant programs: a survey of physician assistant program directors. J Phys Assist Educ. 2010;21(2):22–30.
Journal of Physician Assistant Education
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
Introduction of an Interprofessional Oral Health Curriculum Oren Berkowitz, PhD, MSPH, PA-C, Laura B. Kaufman, DMD, Matthew Russell, MD, MSc Purpose Physician assistants can incorporate a variety of oral health services into their practices, but many physician assistant programs do not dedicate adequate time to oral health education. Our goal was to develop a novel and interprofessional oral health education curriculum model for our physician assistant students that could be adopted by other physician assistant programs and dental schools in the United States. Methods Curricula were created collaboratively and taught by dental school faculty with a focus on the primary care setting. Prewritten and postwritten tests were administered along with a clinical skills examination. Student and faculty evaluations were administered for pedagogical evaluation.
Feature Editor’s Note: Physician assistant educators are constantly faced with adding curricular content to stay abreast of advances in medicine. Measuring the effectiveness of newly developed instructional content is necessary to assure that actual student learning occurs. This article describes the integration of a new oral health component into an existing curriculum (planned as a 2-phase implementation) and offers a model for assessing outcomes of the initial offering. Faculty and student evaluations of the instructional delivery combined with measures of cognitive performance (pre/ posttests and a later final examination) give direction for future curricular enhancements. For the topic of oral health, this model demonstrating interprofessional instruction with PAs and dentists is likely a key to success. Michael Huckabee, PhD, MPAS, PA-C
Results Pretests and posttests demonstrated a 25% increase in knowledge acquisition (paired t test: P < .001). Physical examination skills testing achieved a 95% completion rate. Student and faculty evaluations demonstrated high satisfaction rates with the curricula delivery. Conclusions Initial evaluation of this novel interprofessional curriculum for physician assistant students demonstrates that it was successful. It was well-received by the students and the faculty members and resulted in measurable knowledge acquisition. This model could feasibly be reproduced in other institutions for oral health education.
education, and prophylactic fluoride applications.2,3 PAs can incorporate aspects of oral health in a cost-effective manner and serve a wide variety of patients who otherwise may have little or no access to dental care.4 Many PA programs have little time in the curriculum for the topic of oral health. A recent survey found that close to 75% of PA directors recognized the importance of oral health education for their students, although most believed that a minimum of 5.3 instructional hours was necessary. In contrast to these findings, fewer than 25% of PA programs included any oral health education in their curriculum, with those including oral health education averaging only 3.6 hours.5 The Boston University School of Medicine PA Program (BUSMPAP), together with our colleagues at the Boston University Henry M. Goldman School of Dental Medicine (HMGSDM), developed a novel and interprofessional oral health education curriculum for our PA students. Our aim is to permanently integrate this new and sustainable model into our core curriculum through inclusion in our clinical medicine course. We anticipate that this model could be adopted by other PA programs and dental schools in the United States.
INTRODUCTION As front-line clinicians, physician assistants (PAs) often provide a first line of defense in oral health for their patients.1 Policy advisors report that nondental primary health care providers, such as PAs, can integrate oral health into their routine examinations with oral health screenings, preventive dental
The authors declare no conflict of interest. J Physician Assist Educ 2015;26(1):43–46 Copyright ª 2015 Physician Assistant Education Association DOI 10.1097/JPA.0000000000000014
March 2015 Volume 26 Number 1
METHODS Learning objectives and outcomes were created collaboratively between the BUSMPAP faculty course directors and the HMGSDM faculty lecturers. A 2-part curriculum was developed to take place in the first and last semesters of the didactic year. All lectures and laboratory time are taught by a HMGSDM faculty member. The focus of the oral health curriculum is the primary care setting with competency development in oral health screening, patient education, and the use of appropriate referrals. A 2-hour general introduction to oral health was delivered during the Introduction to Clinical Medicine course in the first 43
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT semester. A 1-hour Overview of Oral Health lecture was followed by a 1-hour oral/dental examination skills session in clinical simulation rooms. The examination skills session was facilitated by 2 HMGSDM core faculty members, a dental fellow, and a dental student. The PA students had the opportunity to learn and practice the oral health screening examination on each other. These sessions took place after the head and neck portion of the Introduction to Clinical Medicine Course to contextualize oral health and teach students how to perform an oral health screening examination. Program Evaluation This newly developed curriculum was evaluated in several ways. The first part was assessed through peer review by BUSMPAP faculty, written student evaluations, multiple-choice examination, and clinical skills examination results. The peer evaluation of the session was performed by 2-core BUSMPAP faculty members who attended the lecture and laboratory sessions. Both the peer evaluation form and the student evaluation form were taken from our existing programmatic evaluation tools used for all courses. The peer evaluation form consisted of 31 items on a Likert scale of 1–5, with the student evaluation also on a Likert scale. A novel demographic questionnaire was developed and administered to the students to quantify the demographic distribution of the class and ascertain any experience in the dental field. A written test was created to assess baseline oral health knowledge and knowledge acquisition from the first oral health didactic session. The test, consisting of 10 multiplechoice questions relating to the learning objectives of the first session, was administered a week before the first session. The same test was administered again after the first session. The examination included questions on basic oral anatomy, professional roles, public health issues, education, and prevention. The students were not permitted to review the test, the answers were not discussed, and the scores were not reported to the students. Oral health items from the clinical skills laboratory were integrated into the Introduction to Clinical Medicine final examination. This was a comprehensive head-to-toe physical examination test that occurred at the end of the summer semester. The oral health portion included 9 items that related to inspection of extraoral structures, intraoral structures, dentition, and gingiva. Informed consent was obtained from all participants before participation, and this study was exempted as educational research by the Boston University Medical Center Institutional Review Board. This project was
supported by grant funding from the nccPA Health Foundation.
RESULTS All PA students (n = 25) participated in the curriculum and program evaluation. The class comprised 40% males with a median age of 24 years (range, 22–37). None of the students reported ever working clinically in the oral health field. One student reported working as a receptionist in a dental clinic for one year. The learning objectives of the first-hour didactic session included the roles and interactions of PAs and dentists as part of an interprofessional health care team, normal oral anatomic structures, abnormal oral findings, oral and extraoral cancer, common oral health conditions, the public health burden of oral disease, and prevention of oral diseases. The second-hour laboratory session focused on a comprehensive intraoral examination that can be performed in a typical outpatient medical examination room setting. Examination skills included the proper manipulation of the tongue, visual inspection of high-risk cancer areas, and how to use a dental mirror to view hard-to-see areas of the mouth. The faculty peer evaluations of the oral health lecture resulted in an average of 4.77 (5 representing high satisfaction), and the student evaluations of the lecture resulted in a mean score of 4.7. The student evaluations of the laboratory session resulted in an overall mean score of 4.59 across all the 4 laboratory facilitators (range, 4.5–4.62) (Figure 1). The mean score on the pretest written examination was 63% (SD = 13), and the mean score on the posttest was 88% (SD = 9), representing a statistically significant improvement of 25% (paired t test: P < .001) after the session (Figure 2). The clinical skills final examination of the Introduction to Clinical Medicine course resulted in an average score of 95% for the 9 oral health-related items (Table 1).
DISCUSSION Our results show that the introduction of the interprofessional oral health curriculum was well-received by students and faculty. Although our student population had no previous experience in clinical oral health, implementing these curricula resulted in statistically significant knowledge acquisition. Students averaged a 25% increase from baseline on a 10question examination after receiving 2 hours of classroom and laboratory instruction. They also exhibited successful clinical skills acquisition related to the oral examination.
Figure 1. Survey evaluations of classroom and laboratory sessions by students and faculty.
44
Journal of Physician Assistant Education
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT
Figure 2. Written examination pretest and posttest results of students’ general oral health knowledge.
This brief report presents the findings of the first phase of a 2-part curriculum in oral health for our students. A total of 12 hours of oral health education is planned for the curriculum over the next year, well above the reported national PA average of 3.6 hours and exceeding the 5.3 hours recommended by PA program directors.5 Although the curriculum is divided over the course of one year, the vertical integration of oral health is expected to result in long-term retention of oral health knowledge and skills. The general concepts of oral health were introduced early on so that students are comfortable with the basic knowledge. The oral examination skills were taught within a month of the head and neck curriculum, emphasizing the intraoral and extraoral components of the patient physical examination. The general topics will be revisited at the end of the didactic curriculum, at which time new specialty topics will be added. This schedule will provide students with a broader context in preparation for the
Table 1: Oral Examination Skills Test Item Performance (N = 25) Oral Examination Skill
Score (%)
Upper lymph nodes
100
Inspect oral cavity
100
Inspect tongue and floor of mouth
100
Inspect lips, labial/buccal mucosa
96
Inspect teeth
96
Inspect gums
92
Lower lymph nodes
92
Comment on oral hygiene
88
Inspect hard palate and oropharynx
88
March 2015 Volume 26 Number 1
specialty topics that will be discussed toward the end of the didactic year in phase 2. Goals and Direction for the Future One of the main goals of this project is interprofessional collaboration and education. Through this collaboration between BUSMPAP and HMGSDM, both the students and faculty members have benefitted from working and learning together. The students are taught directly by experts in the field of dentistry and have a chance to interact one-on-one with the dental professionals in the skills laboratory. The faculty members are able to learn about each other’s program structures and pedagogical methods. Our collaboration has become visible throughout our institution, and the medical school has expressed an interest in developing oral health educational activities and collaborations for medical students, as well. In the second phase of our curriculum, we will teach specialty topics such as oral health in pregnancy, geriatric oral health, and pediatric oral health. At that time, students will undergo a more rigorous assessment aimed at better evaluating their competencies. A qualitative assessment is planned for the end of the BUSMPAP didactic year to gauge the students’ attitudes toward learning in an interprofessional environment. We will also readminister the same 10-question examination at the end of their didactic year to measure long-term retention.
CONCLUSIONS Oral health is a topic that has been inadequately addressed in PA education. The BUSMPAP and the HMGSDM worked collaboratively to develop an interprofessional curriculum for PA students taught by HMGSDM faculty. As reported here, the first part of the curriculum was successful and could feasibly be reproduced in other institutions. It was well-received 45
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
BRIEF REPORT by the students and the faculty members and resulted in measurable knowledge acquisition. This was the first step in a 2-step curriculum process, which will culminate at the end of the didactic year. The programmatic evaluation will continue with a qualitative assessment of the PA students’ interprofessional learning attitudes and further clinical competency assessments. Oren Berkowitz, PhD, MSPH, PA-C, is Director of Research for the Physician Assistant Program and an Assistant Professor of Medicine at the Boston University School of Medicine. Laura B. Kaufman, DMD, is Clinical Assistant Professor in the Department of General Dentistry of the Boston University Henry M. Goldman School of Dental Medicine and a Clinical Assistant Professor, Section of Geriatrics, in the Department of Medicine at the Boston University School of Medicine. Matthew Russell, MD, MSc, is Medical Director for Hebrew Senior Life Rehabilitation Services. Correspondence should be addressed to: Oren Berkowitz, PhD, MSPH, PA-C, Boston University School of Medicine Physician Assistant Program, 72 E.
46
Concord St. L801 Boston, MA 02118. Telephone (617) 638-5744; Fax 617-638-5204; Email: [email protected]
REFERENCES 1. Institute of Medicine. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011. http://www. hrsa.gov/publichealth/clinical/oralhealth/advancingoralhealth.pdf. Accessed February 6, 2014. 2. Riter D, Maier R, Grossman DC. Delivering preventive oral health services in pediatric primary care: a case study. Health Aff (Millwood). 2008;27(6): 1728–1732. 3. Cantrell C. Engaging Primary Care Medical Providers in Children’s Oral Health. National Academy for State Health Policy; 2009: Portland, ME. 4. Essary AC; Clinical and Scientific Affairs Council of the AAPA. Oral health: caring for primary care patients. JAAPA. 2011;24(5): 27–28. 5. Jacques PF, Snow C, Dowdle M, et al. Oral health curricula in physician assistant programs: a survey of physician assistant program directors. J Phys Assist Educ. 2010;21(2):22–30.
Journal of Physician Assistant Education
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
