THEMATIC ARTICLE

Barry Schwartz
The Continuum of Dental Ethics at Schulich School of Medicine & Dentistry, the University of Western Ontario

At the Schulich School of Medicine & Dentistry, the University of Western Ontario, we have had the opportunity to develop what we think is an exciting ethics component within the teaching responsibilities of the Division of Practice Administration. We have strived to develop an educational program that integrates the theories and principles of ethics, law and inter-personal communication with practical clinical experiences.

Our philosophy is to keep it simple, relevant and interesting. In order to engage the students, we feel that it is necessary to provide students with material that they can relate to, perceive as being relevant to their professional lives, and which will stimulate them to critically appraise each situation as a unique event. Students can then begin to apply their newly acquired skills in decision-making, ethics and inter-personal communications effectively. The ethics program involves 66 hours, which is a considerable amount of student contact time over the four years of study.

Year 1

Year one devotes 22 hours to an introduction to; ethics, inter-personal communication, dental law/ jurisprudence, and Royal College of Dental Surgeons of Ontario (RCDSO) regulations. We feel that jurisprudence ethics and communication are integrally related because of shared underlying core values. In that regard, inter-personal communication becomes the practical application of dental ethics and jurisprudence. The purpose of the communications aspect of the teaching is to point out and emphasize the role of communication in interpersonal relationships in general, and in the practice of dentistry in particular, and introduce the student to skills that will promote effective verbal and non-verbal communication.

The incoming first year students’ first exposure to the topic is at the White Coat Ceremony. Here, they not only receive their symbolic white coats (clinic gowns), but also are informed concerning the obligations that a member of the dental profession must meet. In front of their families, and representatives of the regulatory body (RCDSO), organized dentistry (ODA & CDA) and the dental school’s faculty, and senior representative of the dental student society (UWODSS), the students take a solemn oath to be patient-centred and uphold the highest levels of integrity that defines our profession. Photographs are taken during this ceremony and later incorporated into interactive discussions on ethics in order to help the new students identify with being an active participant rather than just an observer, and to build on the purpose and emotion of the White Coat Ceremony.

In the first week of the curriculum, students are asked why they chose dentistry as a profession. Students arrive at dental school driven by a multiplicity of factors including; money, prestige, recognition, being a respected member of the community, parents who are dentists and sometimes, a desire to help others. Most of the motivation is self-serving, so the challenge is to develop within the students a professional philosophy that is centred on the ethic of care. The role of the instructor is not to provide answers, but to encourage the students to look inward for the answers that challenge their own attitudes and perceptions, as well as those of their peers.

The history of dentistry is used to reinforce development of professionalism in dentistry, since it is hard to know where you are going when you don’t know where you have been. The various mechanisms of decision-making as outlined by O’Toole (1) are presented in an attempt to have students understand their own basis of decision-making and to learn tolerance of other perspectives.

Using casuistry, which is applied ethics using case-based reasoning, we encourage the students to focus equally on positive ethics, such as role models, as well as on the negative ethics that are often portrayed in the case studies and to apply critical thinking. Our cases are discussed with interactive participation on finding solutions as we apply our ethics/ communications “toolkit” and decision-making skills. Using real cases and recent examples from the media, we integrate the ethics/communications concepts of informed consent, conflicts of interest, managing difficult patients, conflict resolution strategies, and finally a two hour discussion of dentistry in the media where we critique film clips portraying values of dentists in film and television. By the end of their first year, the students are well positioned to identify the challenges of clinical dentistry that go beyond the technical operative skill difficulties.

Measuring Outcomes

There are three required assignments, worth 60% of their final grade, over the term that enable the students to apply the knowledge they have gained from the teaching sessions. A final examination (40%) allows for grading of important skills and concepts in ethics/communications as well as in critical appraisal of the dental literature, which is another important cornerstone in our Practice Administration course.

The first assignment comes early in the term (6 weeks) and requires the students to write a comparative analysis on professionalism; comparing and contrasting other professions to dentistry such as an auto mechanic and a real estate agent, and this past year, dental hygienists following the recent changes to the Dental Hygiene Act that permits self-initiated controlled acts of scaling and root planing. The purpose is to understand the unique obligations dentists find themselves in and to respect and have tolerance for other professionals, even though they may follow different models of the professional/client relationship. The roles of gender and professional values are also key components of this assignment.

The second assignment involves an in-depth analysis of an ethics case. Each year a new case is written based on recent unpublished ethical challenges that are developed from real-life encounters of former students and colleagues. The students can then apply critical thinking and integrate Codes of Ethics, weigh values and appraise competing ethical principles along with their own preferred decision-making model as they evaluate all conceivable options. They must then describe the shortcomings of the approach that they have chosen before delivering a decision towards the dilemma.

The last assignment, and probably the most significant from an applied learning perspective, is the personal reflection journal, where the students must record and analyze one positive and one negative experience that they have been directly involved with. They reflect on their feelings and those of others and attempt to understand the whole person concept which includes not only biological issues (pain, caries, etc.), but the psychological and socio-cultural influences that are integral to successful patient management. In this way they can reflect on the professional values that are at play and the relationship of those values towards their personal and professional growth and potential implications towards professional interactions. By identifying defining moments in each of the student’s own lives, it is hoped that the students will become more reflective practitioners, who will learn equally from their successes and failures, and hopefully, will serve to enable them to strive for optimum patient care, greater professional collegiality and self-fulfillment.

Year Two

Year two involves the application of a new educational intervention. In 2009 I, along with my co-investigators Judy McCormick and Richard Bohay, were the recipient of the University of Western Ontario’s Innovation in Teaching Fellowship for a new educational intervention entitled “Evaluating the Introduction of a Patient’s Voice in Dental Education Through Reflective Experiential Learning and Self Reported Changes in Empathy.” We believe that optimum inter-personal relationships in a dentist-patient relationship are central to enhanced patient care and development of a trusting professional relationship. In order to enhance such relationships, dentists must see patients as more than an illness or a treatment. Understanding the whole patient is also related to assisting dentists in becoming reflective practitioners. Integrating a patient’s voice into dental education attempts to develop a more humanistic approach towards the dental education journey.

A series of patients shared their personal accounts of their dental experiences on video. Many of the patients were socio-economically and/or medically compromised. They ranged from the working poor, those on social assistance programs and those afflicted with HIV. Others suffered dental treatment errors or suffered the indignity of being fired from a dental practice. Some patients shared stories of wonderful long-term professional relationship experiences with their dentists. Over five classes in the second year, three to five videos were viewed daily followed by an interactive discussion of the patients’ and the students’ feelings.

Measuring Outcomes

Grading in this course involves in-class quizzes to record on paper, key statements that would impact on the patient’s dental care. These are designed to improve the students’ active listening skills. Evaluations are carried out on their reflective journals where students select one of the videos and discuss the impact that it had on their professional growth and values.

Year Three

In third year, the students have their own portfolio of patients and must master not only the technical aspects of dentistry, but also the patient management aspects as well. Consequently, the ethics/communications instruction becomes much more relevant. The third year program has seventeen hours devoted to the application of ethics and communications. The themes of dentists in society, dentists as colleagues and dentists in research are advanced in this year. In so doing, the students can appreciate the responsibilities and obligations required of an ethical practitioner. Lectures are presented on varied topics such as access to care, standards of care, dealing with error, specialist relationships, research, and applied communications. A patient’s voice has been integrated into some of the topics with pre-recorded videos of patients sharing their personal experiences in areas such as lack of access to care and marginalized HIV positive patients. This is part of a divisional research study to explore self-reported changes in empathy in dental students and the potential benefit of using patients as teachers. Following the videos, in-class assignments are held to record salient disclosures that would impact on their care and which serve as a tool to assess reflective listening skills.

Active learning is integral to effective teaching. Peer-to-peer learning is encouraged and students are asked to prepare and act out ethics cases in groups, and then lead discussions on the learning objectives. After all, dentists need to be effective one-on-one teachers with their patients and learn to work as effective team members to optimize professional patient care. Students are placed in groups that integrate different gender and cultural backgrounds as well as with the International Trained Dentist (ITD) students, who only join the class for the last two years of study. This is done purposefully to promote a more harmonious class and the positive aspects of diversity.

Standardized Patient Workshops are introduced in third year to allow the students the opportunity to enhance their inter-personal communications skills and application of ethics by identifying areas that need improvement and to reinforce their strengths. The students, in groups of four plus a facilitator and a standardized patient, must conduct a mock patient interview that has underlying ethics and communications challenges. The students take turns as the interviewer on different cases and are also required to provide peer feedback, both positive and negative, for their peers. Scenarios include challenging topics such as; breaking bad news, non-compliant patients, treatment error/failure, boundaries, privacy, dental phobias etc…

Measuring Outcomes

As in first year, there is a de-emphasis on written examinations and more emphasis is placed on participation and application of acquired knowledge. The grading is done partly by empowering the students to grade the group presentations, which are balanced equally with the instructor’s grade, as well as grading their group teammates for professionalism and participation (20%). There is equal weighting (20%) on the hands-on communications workshop and a third year personal reflection paper (20%) in which the students are asked to re-examine their 1^st year reflections as well as reflect on first hand personal clinical experiences in third year. A final written examination, weighted at 40%, completes the student evaluation.

Year Four

In the fourth year, ethics and communications are integrated with the regulations and guidelines affecting dental practice. Topics such as the ethical treatment of staff and colleagues, boundary issues and advertising/marketing are discussed in small group seminars. Another Standardized Patient Workshop involves the application and integration of legal responsibilities along with the ethics and communication dilemmas in more challenging scenarios. Twelve hours are devoted to ethics/communications and ten hours towards risk management and jurisprudence.

Measuring Outcomes

By fourth year, all student grading in ethics/communications is accomplished through participation and workshop performance. By this time in their dental education, they are expected to think independently and to use their communication skills appropriately. Formal written testing would not, in our opinion, be appropriate. There is however, formal testing in human resource management (Labor Relations, Human Rights, etc.). Although not formally part of the undergraduate curriculum, there is an examination on jurisprudence administered by the Royal College of Dental Surgeons of Ontario. This is a prerequisite for a certificate of registration in Ontario.

Future of Dental Ethics at Schulich Dentistry

Currently at Schulich Dentistry, the curriculum is being reviewed and revised to be more integrated and collaborative between the various disciplines. We would like to involve clinical instructors in monitoring ethics and professionalism exhibited by the students in the clinics and to recognize positive ethics. We also would like to have clinical instructors act as role models for the students. As well, we encourage the students to advocate for patients in need and, as alumni, to financially support the dental school that has opened the door to a rewarding profession thus reinvesting in the future of the profession.

We are continually searching for innovative methodologies to reach students meaningfully. We are fortunate at the University of Western Ontario to have funding opportunities that support and encourage innovative educational pathways in ethics. Informal verbal feedback and more formal student evaluations of teaching provide feedback and insight that serves to improve the content and the presentation of our material. Encouraging students to become reflective learners is integral to lifelong learning. This is a pillar of dental professionalism and an essential part of the continuum of dental ethics from dental school throughout professional practice. We, at Schulich Medicine & Dentistry, hope that through this continuum of ethics in this course, the students will be able to integrate the core values of professionalism, principles of ethics and inter-personal communications skills as a practical application. In this way, they will be enabled to earn greater trust from their patients and become future leaders in their communities and the profession of dentistry. 

Acknowledgments

This course in dental ethics could not be possible without the ongoing support off the following people: Harinder Sandhu (Director of Schulich Dentistry UWO); Richard Bohay (Assistant Director, Academic Affairs); my mentors David Ozar (Loyola University) and David Banting (Chair, Division of Practice Administration UWO), and my colleagues at the Joint Centre for Bioethics U of T; and finally to my colleagues in the American Society for Dental Ethics who bring dental ethics educators together for exceptional workshops.

Footnote

1. O’Toole, Brian. Four Ways We Approach Ethics. Journal of Dental Education Nov.2006 Vol 70 (11) 1152-8

About the Author

Dr. Barry Schwartz DDS, MHSc (bioethics) is Assistant Professor in Practice Administration at the Schulich School of Medicine & Dentistry University of Western Ontario, London Ontario Canada.

Correspondence

The author can be reached via email at: barry.schwartz@schulich.uwo.ca

Citation

Schwartz, B. (2009). The Continuum of Dental Ethics at Schulich School of Medicine & Dentistry, The University of Western Ontario. Bulletin of the International Dental Ethics and Law Society 9(2), 27-33.