Research Article
Preclinical Patient Case Scenario as an Aid to Clinic Preparation: “A Day in the Clinic”
Gary L Drahos*
College of Dental Medicine, Midwestern University, Downers Grove, Illinois, USA
*Corresponding author: Gary L Drahos, College of Dental Medicine, Midwestern University, Downers Grove, Illinois, USA, Tel: +1 6305157473; E-mail: gdraho@midwestern.edu
Citation: Drahos GL (2017) Preclinical Patient Case Scenario as an Aid to Clinic Preparation: “A Day in the Clinic”. J Dent Sci Res Ther 2017: 1-16. doi:https://doi.org/10.29199/2637-7055/DSRT.101012
Received: 27 June 2017; Accepted: 31 August 2017; Published: 27 October 2017
Abstract
Introduction: Pre-clinical dental curriculum, even when taught in an integrated manner, often does not prepare the student to provide competent, ethical patient care of the highest quality or aid with their transition to the patient care clinic. Student competencies are usually assessed in only one specific area and not contextualized in a patient care scenario. Exposing preclinical students to a high fidelity simulated patient care scenario will help the student develop critical thinking and dental treatment skills that will prepare them to plan for actual patient treatment in the clinic.
Methods: A patient scenario was developed that integrated multiple disciplines and contextualized common clinical situations that are encountered daily when treating patients in the clinic including interviewing skills, basic diagnostic skills, manipulation of electronic patient records, material selection and defense of selection, oral pathology diagnosis, image and data procurement, critical decision making, treatment planning and performance of dental treatment. This scenario was designed for second year dental students to be completed in a 3½ hour session. The students were required to make critical patient care decisions and self-assess their performance. Faculty assessed student preparedness for the clinic by applying criteria sheets that were developed for each case.
Results: Students generally completed the session on time and in a satisfactory fashion. Preparation for the session was key and faculty calibration was essential.
Conclusion: Completion of this case scenario better prepared the students for the clinic as indicated by student self-assessment, post course satisfaction surveys, narrative comments, and faculty assessments.
Keywords: Clinic Preparation; Critical Thinking; Dental Materials; Electronic Health Record; Oral Pathology
Educational Objectives
After completing this simulated patient session, learners will be able to:
Introduction
Preclinical curriculum is designed to teach basic foundational knowledge. A dental education must build on basic understanding of dentistry (with additional knowledge in the biomedical sciences) that the student can apply to simulated clinical scenarios and ultimately clinical cases. The first two years in a typical dental curriculum are devoted to ensuring that the students acquire this foundational knowledge prior to dental treatment of patients. The challenge has always been to create a clinic atmosphere in the preclinical environment. Most assessments of preclinical patient skills are in the form of Independent Clinical Performance Assessments (ICPA) that test only one focused aspect of the clinical experience (specific restorative preparations, restorations, endodontic procedures etc.). Some sessions involving simulated patients have been developed using the case scenario basis, but most have been for testing purposes [1,2] or for defined areas of dental practice such as oral surgery [3], or the geriatric [4], or removable partial dentures [5]. Search of literature reveals no case scenarios have been developed that have electronic health record, manikin performance, and simulated patient components. Simulated patient scenarios using an electronic health record, posted patient narrative and faculty acting as simulated patients, contextualizes learning concepts in preparation for patient care. The simulated patient also provides a realistic insight into actual routine clinic situations requiring multiple levels of critical thinking, decision making, organization and time management skills. A pre-clinic session, that has the same time allotment as clinic treatment sessions (3.5 hours), is designed to mimic uncomplicated patient treatment scenarios that present routinely in the clinic.
This simulated patient scenario was developed to allow faculty to assess student skills, provide for student self-assessment and demonstrate individual performance. In this scenario second year dental students were scheduled to work in pairs on the assigned patient and perform dental procedures. This case scenario required demonstrations and performance of indirect restorations, direct restoration tooth preparation, impression procedures, 4 handed dentistry, occlusion, esthetic restorations, radiograph procurement and interpretation, and a detailed daily treatment note using a template. The students were required to demonstrate competency in the following: patient interview, demonstration of blood pressure procurement, diagnosing common oral pathology (Geographic Tongue), patient data collection and recording in the EHR, evaluation of oral health, and restoration material selection. Faculty act as the patient and answer any student’s questions concerning existing conditions, current health and determination of restoration material selection. Student’s professional and clinical skills were assessed by the following methods: student self-assessment using criteria sheets that have been established throughout the first two years, independent performance and faculty observation. Faculty calibration was important for success of this session. Following completion of the “Day in the Clinic” session the students should be better prepared to provide competent, ethical patient care of the highest quality and aid with their transition to the patient care clinic.
Methods
The rationale for including a preclinical patient scenario in the curriculum, is to allow the student to apply basic dental knowledge and perform basic dental procedures in the context of a simulated patient. The essence of the “A Day in the Clinic” session is creating a plausible, uncomplicated simulated patient that requires routine dental treatment and has common health conditions. This scenario requires multiple areas of decision making that allow the student to demonstrate critical thinking, diagnostic abilities and skill in providing dental treatment. The complexity of this case is commensurate with the timing of the basic knowledge that the student has accumulated at that point in the curriculum. This simulated patient was created by representative faculty from the various teaching disciplines and specialties. This patient scenario consisted of three parts.
The Electronic Health Record (EHR)
The first component (Appendix A) is the patient’s Electronic Health Record (EHR) which contains the treatment plan and the treatment to be accomplished on the day of the session as well as the patients’ health history, dental history and previous dental visits. Key components for the patient treatment are contained in the EHR (such as medications, preference for restoration material, radiographs and photos, health and dental histories). This electronic health record John Doe was created and duplicated to each student’s active patient roster in the electronic health record at the beginning of the course.
The narrative part
The case scenario narrative component (Appendix B) gives information about the patient as he presents for today’s appointment. The student must factor in this information when considering today’s treatment (blood pressure, oral pathology and special instructions for the students). The narrative aspect of this case was posted to the all students on an electronic website at the beginning of the course.
The faculty
The supervising faculty serve in the dual role as observing faculty (for assessment purposes) and the patient (for the student to ask questions and obtain information that might affect the day’s treatment such as new medications, oral conditions, restorative material preferences etc.) (Appendix C). The session is implemented in the summer quarter for the second year dental students. They had at this time completed 6 quarters of preclinical curriculum. The class of 128 students was divided into 16 groups of eight students. One faculty member facilitated each group for a total requirement of 16 faculty.
During the session
The students should be graded using the grade sheet (Appendix D):
Each student has this patient reproduced to their individual patient base in the EHR and they must both enter the information individually in their patients record. The session concludes with the daily treatment note following a six-part template created for the exercise (Appendix E).
Format
The scenario requires the students to work as a paired team, with one performing dental treatment, and the other assisting (students previously have been instructed in 4 handed dentistry utilization). Two students in the DMD2 class were paired randomly (Student A and B). The patient is treatment planned to have 2 procedures completed on the day of the session (a restorative procedure and a crown procedure). The restorative procedure is to be performed by student A with student B acting as the dental assistant, and the crown procedure was to be performed by student B with student A acting as the dental assistant. The choice of which dental student did which procedures was up to the paired student team. All dental treatment procedures are to be performed on a typodont that is positioned in a dental manikin.
Session Components
Patient presentation to the instructor
The students will provide a concise and organized presentation of case facts to the supervising instructor prior to proceeding with patient treatment. Key factors that were provided in the narrative summary were a change in measured Blood Pressure (BP), a requirement to procure and attach a radiograph of #18, a requirement to demonstrate the proper procurement of the patients BP (on each other), and the patient reporting a recurring oral lesion that he describes and requests a diagnosis and treatment options.
18 MO restoration
The previous EHR treatment note calls for an MO restoration to be placed in tooth #18 (radiograph provided), but the restorative material is not specified. The EHR is vague in that the patient states, in the dental history section “I want my teeth fixed. I want the strongest fillings you can place. Please make them esthetics, but metal fillings are OK also”. The students paired to this case will have to decide what preparation and restoration to place (amalgam or composite). It is anticipated that the students will need to interview the “patient” (instructor) to present the characteristics of the two materials and determine what the patient wants to be placed. Patient decisions need to be made with consideration for the merits of both materials as well as esthetics, longevity, abilities of the student and cost. It is expected that prior evidence based research on this topic will be performed by the students so that an organized presentation to the patient (faculty) is made on the date of the session with factual basis (student opinion that one restorative material is stronger than another needs to be based on research results). The patient (faculty) will decide what material will be used and Student A of the pair of students will proceed with the preparation and placement of the restoration while student B assists.
#30 Metal crown preparation and impression and provisional
The second procedure to be performed is a crown preparation, for an all metal crown, that has been treatment planned for a tooth that has fractured cusps. Student B will perform this procedure and is also expected to procure a triple tray impression of the prepared tooth and make a provisional restoration. The narrative instructions inform the students to make only one attempt at procuring an impression and making a provisional. If the student assessed the results to be unsatisfactory, they are required to explain why the results were unsatisfactory and what corrections need to be made in order to obtain satisfactory results. Student A will assist. The students are allowed to ask the patient (instructor) and questions or interview them in a fashion to obtain information that they think is critical to the dental treatment.
Blood pressure procurement
The students will demonstrate to the instructor, as a team, how to procure a blood pressure measurement with a cuff and stethoscope.
Radiograph procurement and attachment to the EHR
The students are also instructed in the narrative to procure and attach to the EHR a digital radiograph of tooth #30 procured in the adjacent radiology facility using standardized radiology manikins and typodonts.
Oral Lesion diagnosis and treatment
Additionally, in the narrative section, the patient complains of a recurrent issue with his tongue that will require diagnosis. The appearance of the lesions is available in a photograph attached to the EHR. The student is expected to interview the patient (faculty) when formulating a diagnosis. The history of this lesion and analysis of the photo will result in a diagnosis of benign migratory glossitis (geographic tongue) requiring no treatment.
Session Treatment Note in the EHR
The students use a template to create an organized session note (Appendix F).
Assessments
The students were assessed by the faculty using case scenario specific assessment checklists. A unique checklist was developed for student A and student B (Appendix E).
Calibration sessions
Students: were calibrated to the exercise in a lecture format using a PowerPoint presentation. The electronic health record entry for the patient was also demonstrated.
Faculty: calibration to ensure uniformity in student assessment was presented in the lecture format using a PowerPoint, faculty guide and the demonstration of the electronic health record information.
Resources required to present this session, include access to electronic website to post sessional material such as patient narrative scenarios, calibration presentations, assignments and criteria sheets. An accessible electronic health record system (preferably the same one as used by students in the clinic) also is required. The session requirements for dental materials, instruments are contained in (Appendix G). Facilities, faculty and electronic hardware are all items available in a typical dental pre-clinical environment.
Results
One Hundred Twenty-Eight (128) DMD-2 students participated in this session during the summer academic quarter of 2016. Using case specific assessment criteria, student self-assessment criteria and observations, faculty graded the students to have satisfactorily completed 81% of all cases scenario challenges. There were 3 instances where one of the paired students performed satisfactorily and the other was graded unsatisfactory. 55% of the students ultimately chose (and convinced the patient to choose) amalgam as the permanent MO restoration for #18MO. Each successful completion of a case resulted in 1% of their course grade. All students then completed the final exam multiple choice assessment (80 questions) which contained 8 questions related to this session. Outcomes, for this written assessment, were not examined to determine the level of student performance specifically on “A Day in the Clinic” questions. 122 (95% of the class) participants responded to a post session online evaluation with an overall rating of 4.63 out of 5 in the areas of clarity of objectives, organization, evaluation methods and overall rating. Narrative comments (55) were also positive. Two areas that the students seem to have some difficulty with are: 1. The patient interview process to obtain information necessary to diagnose the urgent care problem (faculty portrays the patient) 2. Defending the selection of appropriate restorative material.
Discussion
The concept of “A day in the Clinic” was generated to simulate clinical situations that would occur on a typical clinical patient. Developing a realistic patient scenario that contained components contained in numerous areas of the preclinical curriculum was a positive experience for the students, and gave a palpable feeling of how patient treatment will be performed in the dental clinic. Contextualizing various basic dental knowledge components into this case forced the students to prepare ahead, verbalize a presentation of case facts to the faculty and also organize their plan of action to perform the planned treatment. Performing daily data gathering such as updating medical and dental histories with new information, manipulating the EHR to add radiographs and treatment notes, and defending dental material choices were all pieces of this session. Faculty responses, when role playing the patient, also added an interview aspect to the session. The results of the post course evaluation indicated students found value in this type of session and helped anticipate the real nature of patient treatment in the clinic. The authors are unaware of other courses commonly used in dental school education today that offer a similar level of pre-clinical training experiences in simulation of daily common case scenarios as provided by this session. The material and facilities needed to accomplish these sessions are typical items that are found in every preclinical simulation lab.
The “A Day in the Clinic” concept is not without its problems. Developing an appropriate case scenario is always a challenge. The final goal of completing the treatment in the time allowed and not trying to include too many items into the scenario is important. This simulated patient scenario approach to teaching requires much faculty and student calibration to insure accurate and fair assessing of the student. Criteria forms that are developed for this type of assessment are essential and allow for fair individual assessment.
Suggestions for Expanding the Role of “A Day in the Clinic” Sessions
This patient scenario session can be adapted as the students’ progress through the preclinical curriculum and treatment modalities can be added as their knowledge base increased. For instance, patient consults, fixed prosthetics, complex oral lesions, prescription writing and more can be added to the elements of the scenario as the students develop these skills. Case difficulty and inclusion of more critical thinking decisions and complexity of the dental treatment can increase toward the end of the second year. Patient case scenarios can be tailored to any phase of the curriculum.
Conclusion
The students seemed to genuinely enjoy the multiple procedures that they had to perform during this session as evidenced by their written narrative evaluation and verbal comments concerning this session. Simulating a real clinic case and providing all the treatment necessary for that day required organization, planning and preparation. Working in a 4 handed environment was also a new experience for them. This session gave them a first-hand view of how the clinical treatment of patients would occur and prepared them for treating patents in the clinic. It also helped identify areas of patient care that need to be revisited in preclinical curriculum.
References
Appendix A: Patient electronic health record requirements
Electronic Health Record requirements (EHR)
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Appendix B: Case narrative (posted 1 week prior to the session)
A day in the clinic
Your patient for this session is John Doe. His patient record is available to you in the EHR. The previous treatment note will let you know what is planned for the patient for today. His blood pressure today is 140/85. Another student in your group is assigned with you for this treatment session. There is a 4-handed dentistry component to this session. After reviewing the patient’s chart, you should update the patient’s medical history. The patient has also noticed some irregularities in his tongue that he says reoccurs occasionally. Please advise him as to the most likely diagnosis and treatment necessary.
Tips:
Appendix C: Faculty guide for the session
Faculty guide to “A Day in the Clinic”- Patient John Doe
Prior to the “Day in the Clinic Session”
Students must make restorative material selection as a result of patient (faculty) consultation.
*Have evidence ready to support your claims (is amalgam “stronger” than composite etc.). Be sure of your facts. Amalgam, composite, glass ionomer, temporary.
*Consider the area you are restoring.
*Final restoration or bases.
*Don’t make decisions without consulting the patient (they may think that metal fillings are more esthetic than white fillings).
On the day of “Day in the Clinic” Session (12 - 3:30 PM - or any other 3.5 hour period)
Student A and B Presentation to the assigned faculty
This interaction of patient/faculty and student is an important phase of the session and allows for a thorough determination of the students preparedness and knowledge of the patient, procedures to be performed and patients health in relation to performing the planned treatment.
Appendix D: Self Assessment Criteria Sheets for various procedures performed during the session
1610 All Metal Crown Preparation - Tooth #30 |
Student name: _________________ Date: __________________
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1610 All Metal Crown Preparation – Tooth #30 |
Student name: __________________________ Date: __________________
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Evaluation of Dental Assistant for Foundation Restoration Activity |
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Proximal- occlusal preparation for Resin Composite |
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CDMI
Blood Pressure, Pulse and Respiration Measurement - Evaluation Form
(Student mark finding with an X)
(Instructors circle student’s findings to verify or comment if they disagree)
Student Name: ____________________________ Date: ____________
Faculty Name: _____________________________
Check One Column Below For Each Applicable Criteria
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Appendix E: Checklist for Student A and B
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Image owned by Mary Anne Byrnes used with permission.
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Notes: |
All dental procedures required in this case are familiar to the students and have been performed as coursework during first two years. Student’s work independently checking only final products with the faculty (completed amalgam or composite prep, completed restoration, crown prep, impression and provisional restoration). Students self-assess their work using criteria sheets that are procedure specific (Appendix D). These criteria forms were created throughout the first 2 years as part of dental curriculum. The forms were posted and the student was expected to print these forms in advance and complete their self-assessments independently. Each session was 3.5 hours in duration (the same as the length of our clinic session) and was worth 1% of the student’s grade in the course for successful completion.
Faculty duties during the session:
During the session, the faculty is not to intervene, or steer the student to accomplish any particular component in a certain way.
The faculty can do the following:
Appendix F: Daily Treatment Note
Daily Treatment Note Template and sample note
A. Template for daily treatment general. |
B. Sample of possible general treatment note for the session. |
Appendix G: Session material and instruments used, facility needs and time allotments
Dental Materials needed: (Photos attached below)
Session Preparation:
Pre session (Students)
Post session (Students)
Pre session (Faculty)
Facility Needs
Time allotment (Student)
Faculty requirements
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Restorative Operative/Fixed Kit
Composite restoration materials. |
Rubber Dam Cassette. |
Cuff and Stethoscope. |