Problem-based Learning: An Interdisciplinary Approach in Clinical Teaching

Mohamed NHa and Abdul Kadir Rb

aGeneral Dental Practice, bDepartment of Community Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur

ABSTRACT

A review of the dental curriculum in 1994 at the Faculty of Dentistry, University of Malaya paved way for a five-year programme to replace the four-year curriculum that had been in existence since the faculty was set up in 1972. The new curriculum saw many changes in the mode of teaching which included an interdisciplinary approach particularly in clinical teaching. This provided the impetus for problem-based learning to be included. Such an approach came in the form, among others, of an integrated seminar in the fifth year of dental education which was scenario-based and saw the inclusion of various teaching disciplines in dentistry. The objective of the problem-based learning approach was to develop and promote critical and analytical thinking skills of dental students in the university’s effort to improve their decision making ability. In so doing, students in small groups were expected to learn to work together to identify learning issues from real-life situations, develop skills to resource and critically analyzed appropriate and relevant materials and subsequently, came to a consensus of the ‘best’ method to manage the issues at hand. The learning process was enhanced with the presence of faculty staffs taking the role of facilitators. Assessment of the final year students showed that they perform better as clinicians through the use of this mode of teaching.

Introduction

Faculty of Dentistry, University of Malaya in Kuala Lumpur was established in 1972. This is the first dental school in Malaysia. The first group of 47 dental students and underwent a four- year curriculum leading to the Bachelor of Dental surgery. At that time, the objective of the faculty was to produce qualified dentist and to serve the government dental clinics. A review of the dental curriculum in 1994 paved way for a five-year programme in the faculty. In fact, this new curriculum facilitates the recognition of the faculty by the General Dental Council of Great Britain in December 1997.

The five-year course is conducted into 2 phases; pre-clinical phase for 2 years and clinical phase for 3 years. The components for the 5-year curriculum are as in the Table 1. The dental students received almost all their basic sciences instruction (pre-clinical) at the faculty of Medicine, University of Malaya while been supplemented with dental subjects in essential areas such as oral biology and anatomy, oral pathology, oral radiology, dental materials and technology, and social behavioural sciences. In the second year, dental students began their discipline-based subjects such as operative dentistry where they work on simulated dummy. The actual clinical dentistry only starts at year three where the dental students began managing and treating their patients by discipline-based. (Table 1).

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Pre-clinical Clinical1st Year 2nd Year 3rd Year 4th Year 5th YearAnatomyPhysiologyBiochemistryHuman genetics& ImmunologyOral Biology

PharmacologyPathologyMedical microbiologyGeneral materials & technologyOperative DentistrySocial Behavioural Science

Human diseasesMedicineSurgeryOral pathologyPreventive Dentistry

General Anaesthesia, Sedation and ResuscitationElective Research Project

General Dental Practice

Community dentistry and posting

Oral diagnosis & radiology

Oral and Maxillofacial surgeryOral Medicine & Periodontology

Children Dentistry & OrthodonticsConservative Dentistry

Prosthetic Dentistry

Table 1. Course Structure of BDS Programme

During the clinical years, the dental subjects that were taught were children dentistry, preventive dentistry, conservative dentistry, oral pathology and oral medicine, oral maxillo-facial surgery, orthodontics, community dentistry and periodontology. Under the new curriculum, a new clinical programme was introduced in year five, namely; General Dental Practice. The programme is aimed at preparing students to provide a broad range of comprehensive oral care to all age groups and through holistic approaches. It is an integrated clinical patient-centered practice.

The Curriculum in General Dental Practice

The curriculum in the practice was designed in which a hybrid problem-based learning approaches was adopted since various teaching modalities were included. The goals of these are for knowledge attainment, clinical skills requisition, and personal skills and development. Among the modalities are didactic teaching, comprehensive clinical practice, case discussion, journal discussion, integrated seminars and field visits to private practice. In the didactic teaching, involvement of part-time practitioners were benefited as an effort to provide students with more exposure and experiences as well as gaining sufficient information on practice management.1 Given limited number of faculty teaching staffs and being a new teaching programme, the part-time practitioners contributed substantially in the curriculum development especially, in the field of information technology and practice management.

During the clinical practice, the patient-centered clinic provides interdisciplinary approach of learning whereby the student experiences examining and treating different

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category of patients during each session. They were trained in oral diagnosis, treatment planning and procedures required according to their learning objectives. After presenting their case, the supervisor in-charge of the clinic will then assessed the level of the competency shows by the student. Provision of optimum care will be carried out accordingly in conjunction with the student proficiency. These will be follow-up with small group tutorials. Teaching/learning modalities No. of students/group Contact

hours/studentLectures 64 20Case discussion 10 - 12 4.5Journal discussion 10 - 12 3PBL integrated seminar 10 - 12 4Clinical practice 10 - 12 96Field work 10 - 12 6

Table 2. Number of students and contact hours across the teaching/learning modalities

Problem-based approaches

In an effort to enhance students’ skill in patient management, selected cases for group discussion were identified according to problem-type. Three or four cases were discussed during the tutorial where relevant information was distributed to the students prior to the tutorial. The above cohesive small-group and student-centered techniques will enable interaction, communication skills and peer assessment to be carried out.2 Journal discussion sessions are also included in the programme, as this will promote critical and analytical thinking for the undergraduate level. Selected journals were identified by the teaching staff basically based on general issues pertaining to clinical discipline.

Another problem-based approach of learning was also conducted by having the integrated seminar where faculty members across all disciplines are engaged to facilitate the session. The class was conducted in a group of 10 – 12 students. Problem-based learning instructional strategies were given to the facilitators before the class. The dental students were then given a task; a scenario of real life problems, which the students work in a team to identify the ‘problem’ and the learning issues. Two sessions were allocated in their timetable for the discussion under the facilitator’s guide and the rest for the group discussion and resourcing information were conducted separately. By having this, they also learn to source the information from different resources such as books, journals, internet or by consulting the experts. The process of learning is a student-centered thus encouraging self-directed learning.3 This authentic problem-based learning will also allow students to be able to reason accordingly their encounters in daily practice. The focus areas of the scenario are occlusion, tooth wear, trauma, dentine hypersensitivity, early childhood caries, endo-dontic-periodontic lesion, impacted wisdom tooth, tooth discoloration, dento-alveolar abcess and medically compromised patient.

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Evaluation and assessment method

The group dynamic is important to be assessed in order to develop effective communication skills, whereby interpersonal interactions and transmission of information has to be look at in this learning process. While they identify appropriate resources and further information, it is also important for them to develop and promote critical thinking skills. Critical thinking may be viewed as an amalgamation of cognitive skills such as the ability to reason, formulate concepts, make appropriate inquiry and translate information.4 Students are also expected to be able to integrate the knowledge, skills and attitudes in the integrated disciplines to enhance their performance as a clinician. It is the responsibility of the faculty of dentistry, University of Malaya to provide quality education to produce knowledgeable, responsible, sensitive, disciplined, with ethical and moral values and multi-talented graduates.5 Reformation of the curricular structure and teaching techniques is the alternative for the future directions in dental school since dentistry as a health profession should be heading towards the oral health needs of the public in the twenty-first century.6 Utilization of case/problem format as a means of evaluation by the national board of examination has also been reported.7

Figure 2. The profile of component in final assessment

The assessment of the final year students in the General Dentistry module is based on the theory paper, clinical proficiencies and continuous assessment (Figure 2). Although the traditional written examination (theory) was widely used the in assessment for the dental student, other approaches such as clinical proficiencies and continuing assessment are also included. Thus it reflects an integration of all disciplines for the clinical year students. The theory part will test students on knowledge attainment, skills of problem solving and decision making where the questions comprises of long questions and short notes. In the clinical proficiencies, the students are required to present a case with formulation of treatment plan. The students should focus on the patient’s needs, expectation and social requirement besides the problem of the patient’s main concern. While in the continuous assessment, attitude, communication skills and group dynamics are assessed according.

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Percentage of student’s scoreYear of assessment

A+ A B C

1999/00 - - 24 252000/01 1 1 29 172001/02 - - 24 40

Table 2. Percentage of student’s score in the final year assessment

Conclusion

The assessment of the final year clinical students showed that there was an improvement in the following year based on the score of their performance (Table 2). Findings from our experience suggest that knowledge and application of knowledge are best tackle by self-directed learning. Students are also observed to have and learn faster through such self-directed learning programme . This problem-based approach is an ideal means of equipping the clinical students with communication skills and group dynamics. It can be concluded that the practice of interdisciplinary approach of clinical teaching in the general dental practice provides positive pathway to skill and attitude development thus facilitates life-long learning.

References:

1. Barrows HS. The essentials of problem-based learning. J Dent Edu 1998; 62(9): 630 – 633

2. Behar-Horenstein LS, Dolan TA, Courts FJ, Mitchell GS. Cultivating critical thinking in the clinical learning environment. J Dent Edu 2000; 64: 610 – 615

3. Hendricson WD & Cohen PA. Future direction in dental school Curriculum, teaching and learning. 75th Anniversary Summit Conference. American Association of Dental Schools.

4. MacNeil MAJ, Walton JN, Clark DC, Tobias DL, Harrison RL. Structuring a clinical learning environment for a hybrid-PBL dental curriculum. J Dent Edu 1998; 62: 723 - 729.

5. Matlin KS, Libert E, McArdle PJ, Howell TH. Implementing the problem-based curriculum at Harvard School of Dental Medicine. J Dent. Edu 1998; 62: 693 -678.

6. Workshop on Interactive Learning & Problem-based Learning Proceedings. Towards Curricula Innovations across Disciplines ( 2002). University of Malaya.

7. Young NA (1998) Problem-based Learning: Using Cases to Drive the Learning Process. J Dent Edu 1998; 62(3): 235 -241

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