Clinical Teaching in the Undergraduate Clinic—More Difficult than It Looks

June 16, 2010

"The 'how can we help you?' attitude is pretty well absent in most faculty members. The denigration and public humiliation, although at times not outright, is still employed."

— Dental student, 19981

"How can we expect students to become humanitarians in the community, active members in organized dentistry, ethical providers of health care, and leaders in our profession if their first three or four years are filled with anger at the very institution that should be instilling these qualities?"

— Dental student, 20082

Dental students are committed to what they do. They arrive at the clinic eager to learn. For years, they have pleaded for better teachers; yet it appears, at least from the comments above, that the dental education community has largely neglected their calls for help.

Admittedly, whether students are becoming less committed to the profession as a result is not clear, nor can we be certain that their performance as practitioners has suffered. Thus, some might argue that there isn't a problem. Anecdotally at least, we still have excellent students. Nonetheless, it is hard to deny that an improvement in teaching will make them better.

The problem is not that clinical instructors don't care. As Virginia Commonwealth University professor Stephen Saroff explained in 1977, "The pedagogical aspects of dental school teaching have been neglected, not because of a lack of interest or desire among faculty but rather because of a lack of preparation for teaching roles."3 Twenty-four years later, a survey4 published in the European Journal of Dental Education found that, of the 51 dental institutions across Canada and the United States that responded, only 21 offered their clinical instructors formalized teacher training.

Eventually, the numbers will change: the dental community will fully embrace the value of teacher training for its clinician instructors, and every clinical educator will have access to comprehensive teacher training before they begin supervising students and facilitating learning. Until then, it is incumbent on individual instructors to prepare themselves as best they can.

Research on teaching and learning emphasizes 3 ideas that each clinical instructor should understand before entering the classroom: the importance of setting an appropriate emotional tone; the role of the instructor as a facilitator of learning; and the responsibility of the instructor to serve as a role model.

Emotional Tone

The University of Florida's Richard McKenzie suggested that instructors who—inadvertently or not—fail to set a positive, engaging tone in their clinics hinder the learning environment.5 As bright as they are, dental students are human beings, and human beings are not perfect. In the words of one expert, students "want to know how much you care, before they care how much you know."6 They are motivated and inspired by teachers who display compassion and demonstrate genuine interest in them as people and in their futures as dentists. Regardless of the potential impact on their abilities or careers, students are more likely to avoid instructors they perceive as uninterested or uninspired. They are less likely to ask questions of such individuals. And they are more likely to disregard such instructors' advice once their class is over.

Students also respond positively to clear and consistent directions and guidelines. Effective instructors articulate the goals of each session and ensure that their students understand what is expected of them. Effectiveness is compromised if students sense that their instructors disagree with the stated goals of the department. They lose faith if the message is not unified and clear.

The Instructor as Facilitator

Effective instructors don't teach so much as they facilitate learning. According to a recent study,7 students describe their most effective teachers as "useful, helpful, and valuable," more often than as "knowledgeable" or "experts." The primary role of the clinical instructor, then, is to determine not so much what students should know as what they do know when they arrive at the clinic. They can do so by asking probing questions and controlling their frustration or disappointment if the answers they receive are incorrect or inappropriate.

Good facilitators anticipate learning opportunities before they arise. Arriving at the clinic early and speaking with the participants before the session officially begins provides instructors with the chance to prepare their students better for the challenges ahead. What will happen, for example, if today's patient seems to have a profound mandibular block but still experiences pain during the preparation? What do you do in the case of unexpected pulp exposure? What scaler do you use to scale the distal lingual surface of a lower third molar? Making students aware of the potential challenges they might face in advance reduces their stress level and increases the confidence they might exhibit when the patient is in the chair.

Self-reflection is another critical component of learning. At the end of a clinical session, before revealing grades or scores, instructors might consider asking their students for a self-assessment. Encouraging students to reflect on the criteria for excellence and to compare their own performance with that standard promotes learning as much or more than any grade. Having heard the student, the instructor can initiate a discussion and then adjust the grade if necessary. Instructors who have not experimented with this process might be surprised by their students' reluctance to assign themselves specific grades. In this case, persistence is worthwhile, as the benefits of the students' self-reflection will be felt by the students and instructor alike.

Facilitating student learning, rather than giving students answers, is a learned skill that takes considerable practice. Nevertheless, once it has been mastered, most instructors will find their time in the clinic more rewarding.

The Instructor as Role Model

Regardless of whether instructors acknowledge it, they are role models. They are what their students are trying to become. Students carefully observe everything their instructor does in the clinic (even if it might not always seem that way). For example, does the instructor acknowledge the patient when first coming to the operatory? Does the instructor say something to the patient at the end of the session? (One careless action at the chair side can undo hours of lecturing about the dignity of patients.) And how does the instructor treat support staff?

Role models never feel that assisting a student is beneath them. They are happy to look at what their students have in their operatory, anticipate what they may need and get it for them. These types of actions save the students time and reinforce the supportive classroom tone that is most conducive to learning. Along similar lines, instructors who are not otherwise occupied can suction for students or serve as their assistants for short periods. In these cases, although the benefits in terms of the student's efficiency are clear, instructors must be mindful of intimidating those who are less confident. Good instructors will also make an active effort to involve junior, observing students in every discussion.

Role models speak to their students about dilemmas that may occur in the course of a practice day. If a procedure fails, does one refund all the money, some of the patient's money or none? If one observes poor dentistry, what is the professional's obligation? Students enjoy participating in these types of discussions and the benefits to the learning process extend beyond the initial dialogue.

Conclusion

In his book, The Creation of the Future: The Role of the American University,8 Frank Rhodes wrote, "Because of its profound impact on the individual student and society, teaching can never be just a job, however demanding. To the best teachers, teaching is a moral vocation. It is moral because it seeks to develop not only comprehension but also commitment; it influences and shapes not only the intellect but also the will, it involves cultivation of not only the mind but the heart. It is a vocation because it is a calling not simply a job."

In our Canadian dental schools, we have some of the best dental teachers anywhere. Hopefully, the efforts suggested here will make their task easier.

THE AUTHORS

 

Dr. L. Chapnick is an associate in dentistry (endodontics) at the faculty of dentistry, University of Toronto, and is in private practice limited to endodontics in Toronto, Ontario.

Dr. A. Chapnick is the deputy director of education at the Canadian Forces College in Toronto and an associate professor at the Royal Military College of Canada in Kingston, Ontario.

Correspondence to: Dr. Lorne Chapnick, 2200 Yonge St., Suite 1009, Toronto, ON M4S 2C6. Email: lorne.chapnick@utoronto.ca

The views expressed are those of the authors and do not necessarily reflect the opinions or official policies of the Canadian Dental Association.

This article has been peer reviewed.

References

  1. A second opinion [letter to the editor]. J Am Dent Assoc. 1997;128(11):1492-94.
  2. Morton NA. Benefits of a humanistic education: a student perspective. J Dent Educ. 2008;72(1):45-7.
  3. Saroff SA. Survey of the perceived educational needs of dental faculty. J Dent Educ. 1977;41(2):81-4.
  4. Chapnick L, Chapnick A. North American survey of teacher training programmes in dental schools [news and views]. Eur J Dent Educ. 2001;5(1):43-4.
  5. Mackenzie RS. The role of curriculum and faculty evaluation in dental education. J Dent Educ. 1981;45(10):678-84.
  6. Christensen R. Every student teaches and every teacher learns. In: Christensen R, Garvin D, Sweet A, eds. Education for judgment: the artistry of discussion. Boston: Harvard Business School; 1992. p. 111.
  7. Jahangiri L, Mucciolo TW. Characteristics of effective classroom teachers as identified by students and professionals: a qualitative study. J Dent Educ. 2008;72(4):484-93.
  8. Rhodes FH. Teaching as a moral vocation. In: Rhodes FH, editor. The creation of the future: the role of the American university. Ithaca (NY): Cornell University Press; 2001. p. 58-83.

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