Fazal Ghani*, Irfan Salim**
Introduction
A substantial proportion of the dental undergraduates, all over the world, work as general dental practitioners (GDP) by providing primary dental care services. To do so better and effectively, they must have undertaken their dental training in a setting that provides holistic and comprehensive dental care to patients.1-5 In addition, most dental patients seeking treatment, though apparently wish the addressing of a particular problem or condition, have many other concurrent conditions and states. These not only need to be identified but will also require treatment by the same dentist
This for example, in case of patients, seeking prosthodontic consultation generally include the identification of the need and provision of various pre-prosthetic medical and surgical, periodontic, conservative dental, oral surgical and orthodontic preparatory work prior to the provision of prosthodontics treatment. Currently the trend is that the provision of such preparatory work is carried out in the relevant dental specialist’s departmental clinics that require the referral of patients to them. This is because in most of the dental schools and colleges the theory and clinical procedures are taught independently by specialists in their disciplines and clinics.
The advantage is that dental students acquire knowledge and working experience about the specialities. However, the disadvantage is that this leads to students coming out of the undergraduate education unprepared for the practice of general dentistry that is expected of them. To familiarize them with the skills of running an independent general dental practice, an additional one year vocational training under the supervision of an experienced GDP is considered more relevant and advantageous in comparison to the one year house job training with rotations in the various specialist clinical departments.6-7
However, a much better approach to producing GDPs who are competent to provide holistic dental care, a concept for undergraduate dental training called as the comprehensive dental care (CDC) training system has been proposed in 1962. In this method, the clinical training incorporating all the specialist disciplines is undertaken by dental students in a single integrated dental clinic.2 This, while bringing a sense of clinical maturity in dental students also imparts, in them, the skills and attitudes for a holistic and comprehensive approach to the practice of dentistry.
This is because, the student is delegated the responsibility, under the supervision of a clinical tutor, of the total dental care of his patients. The student thus remains focussed not only on the specialty specific treatment but also into looking out for the overall treatment needs of the patient. Thus the abilities, competencies and proficiencies of a GDP are better inculcated during the undergraduate dental training of students. At the same time patients receive more coordinated care than that in the traditional specialty based clinics. In fact, a report in 1993 on this approach of undergraduate dental training, already adopted by many dental schools abroad (80% in USA by then), has shown the achievement of improved educational goals and patients’ care. This integrated patient care has become the guiding principle of modern dentistry by avoiding and reducing the segregated departmental approach of patients’ care.4
The objectives of the CDC curriculum are to facilitate and ensure personal and professional development. Students are made aware of the fact that every professional relationship is based on respect of the patient as a person and fulfilment of his treatment needs. Education is focussed on humanism as a frame of reference from ethical standpoints. The curriculum provides students with competence and knowledge that enable them to treat after diagnosing the dental conditions in adults and children with various treatments needs, including the disabled and chronically ill.5 These objectives are achieved by authorizing one student responsible for the total oral care of all his / her patients. The student after assessing the oral health status and treatment needs proposes a treatment plan including preventive measures and prediction of treatment outcome for each patient assigned to him. Students are assigned patients according to their levels of knowledge and experience of patients’ treatment. Those relatively newer and less experienced get simpler cases where as the seniors work upon the more advanced cases. The classification or categorization of the level of treatment complexity pertaining to patients is done by the team at oral diagnosis. This may comprise of members as specialists in cariology, orthodontics, prosthontics, endodontics, periodontics, oral biology and oral surgery to constitute an integrated multi-disciplinary faculty team. A clinical tutor with experience and expertise of general dental practice is an immediate guide that is assigned to a group of students who is responsible for the supervision of students when providing the overall treatment to patients.
Students’ assessment is based upon pre-specified criteria. Most important in this regard is the monitoring of the progress in decision-making ability and skills and professional demeanour as well as of the students ability of providing diverse items of treatments. Each clinical tutor or supervisor of a CDC clinic follows and monitors, continuously, the clinical activities of a group of students for a period of 2-3 years. Thus as supervisor he / she gets a clear insight into each students’ overall clinical progress and competence. This is obviously not possible in the departmentalized system of training since the students departments are changed time and again.
With all this in mind it is to be realized that the current educational approach of departmentalized education and training is leading to students lacking in clinical judgement and maturity when they graduate. In comparison, the CDC clinical training and curriculum prepares students much better able to successfully practice general dentistry and provide primary care dental services, which is expected of them on graduation. Training in CDC clinics not only benefits students but also the patients. In a CDC clinic, patients receive more co-ordinated care and the students acquire a greater understanding of CDC management. There is no referral of patients to other specialist departments that otherwise puts the patient out of sight of students.The adoption of the CDC concept for BDS training by a newly starting dental school should be straight forward with no problems. However, in case of existing dental schools, prior to switching over to the CDC training system, several problems and challenges need to be overcome and accepted. The first one obviously is the re-setting and de-programming of the mentality of the specialist faculty that is currently extremely status conscious and possessive. Their minds must need to be conditioned for accepting the abolition of their own respective specialty kingdoms which they have established and to which they wish to remain clinging.
Therefore, the existing specialist faculty based in their respective departments need to be made aware of the positive effect that switching towards CDC concept will have on their efficacy and productivity. With the start of the CDC training system in their schools, they will not be spending and wasting time in supervising and providing simple and routine treatments that are related to their specialty. For the provision and supervision of such treatment services, tutors and faculty with advanced skills in general dental practice will be available in the CDC clinics. The respective senior professorial faculty will only be involved in the treatment planning and treatment activity of selected patients. Thus, they will have more time for the provision of sophisticated, complex and modern therapeutic options. They will also have more time for high level advisory services, supervision of postgraduate students and for conducting innovative research in their respective fields of specialization.
Another issue of common concern to both the new and existing dental schools is how to address rectification of the current severe shortage of CDC tutors and faculty with advanced skills in general dental practice. This can be done in several ways. The first one is to immediately start a new programme of fellowship in general dental practice at the College of Physicians & Surgeons Pakistan (CPSP) level that would lead to the award of FGDP CPS (Pak) degree. Such training programmes for acquiring advanced level skills and competencies in general dental practice have already been implemented by many countries abroad.6-7 One such programme is the fellowship programme offered by the faculty of general dental practitioners at the Royal College of Surgeons in England (UK).
The other one is the most popular programme of advanced education in general dentistry (AEGD) that is offered by most US Dental Schools. Alternatively, the academic degree programme of MDS in general dentistry should be started by the existing dental institutes and universities.
Secondly, the junior faculty that is currently working in the respective specialists departments also need to be supported for enhancement of their skills of general dental practice and CDC services. This can be done by organizing, for them within their own working places, short on-job training and refresher courses in general dentistry.
Thirdly, utilization and involvement, as faculty, of the experienced GDPs in the locality also needs to be considered. Such competent GDPs need to be identified and encouraged for employment to work on part or full-time basis as faculty for the training and supervision of undergraduate dental students.
This has already been a practice abroad.6-7 Thus there should be no objection from the authorities at the Pakistan Medical & Dental Council (PMDC) on the training of undergraduate dental students under the supervision of part-time or full-time GDPs.
To start with CDC training, ideally, multiple CDC clinics are to be established in a dental school, one for each working day not only to accept new patients on that day but also to continue treatment of accepted patients on the remaining working days of the week. Each such CDC clinic needs to be equipped for the provision of CDC training of students and services to patients. A batch of students from each of the clinical BDS classes shall be attached to observe work of their faculty as well as to provide holistic dental treatment to their patients in their respective CDC clinic during their entire clinical training period.
This for the fresh incumbents shall be a period of 2-3 years. Each CDC clinic will accept patients on the assigned day Depending upon the work-load, patients reporting to the respective CDC clinic shall be interviewed, examined and evaluated either on the same day or given an appointment for the same. As a result, a CDC treatment plan for each patient will be formulated and subsequently executed in the same clinic.
Thus students will be exposed to the real environment relating to the practice of general dentistry. Ethical, competent and proficient GDPs will be thus produced who will know the limits and boundaries of their practice skills and who will be better trained for understanding the comprehensive dental treatment needs of their patients
References
- Ireland RS, Dauber S. Introducing undergraduate dental students to the wider role of the primary care of teeth. Eur J Dent Educ 1999; 3: 144-147.
- Proceedings of the Kentucky Conference on Dental Curriculum. J Dent Educ 1962; 26: 393-413
- Kilgore TB, Casada JP. Clinical educational managements system in the United States and Canadian Schools. J Dent Educ 1994; 58: 775-777
- Advisory Committee on Training of Dental Practitioners. Section II. Competences required for the practice of dentistry in the European Union. XV/ E/ 8316/ 8/ 93.
- Johnson G. A Comprehensive care clinics in Swedish dental undergraduate education: 3-year report. Eur J Dent Educ 1999; 3: 148-152.
- Ghani F.Specialization in dentistry: Some reflections. J Pak Dent Assoc 2004; 13: 240 245.
- Ghani F. Mid-level diplomas in dentistry: Which one is relevant. J Pak Dent Assoc 2005; 14: 54 55