Interdisciplinary Medical/Dental Training Best Practices Report

Lauren Orsini

01/31/13

There has been a historic separation of the medical and dental fields academically and professionally. This separation has made it more difficult to encourage these professionals to work together. Collaboration between the medical and the dental fields must start with interdisciplinary education to provide a foundation for this collaboration throughout their professional careers.

In June 2006, the Family Medicine Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) mandated an inclusion of formal education on oral heath in the family medicine residency programs (Douglass et al., 2009). In June 2008, the Association of American Medical Colleges (AAMC) released a report advocating for greater collaboration between the medical and dental schools and cross-competency training (Douglass et al., 2009). These have been milestones for medical and dental interdisciplinary education and training.

To provide a comprehensive overview of the interdisciplinary training within the medical field, I will outline the best practices in the medical school trainings (including rotations) and in the residency programs. Medical school trainings and residency programs are both critical periods for interdisciplinary training as the training within the classroom will introduce the notion of interdisciplinary training and the residency programs will integrate oral health into the clinical training.

Medical School Education:

In May 2008, the AAMC published an article which emphasized oral health education within medical schools (Fuchs, 2008). This article summarized two reports regarding interdisciplinary medical/dental training (Fuchs, 2008). These reports were prepared by medical educators, dental educators, the AAMC, and the American Dental Education Association (ADEA) (Fuchs, 2008). These reports call for medical and dental students to understand how oral health and overall health affect each other (Fuchs, 2008). The reports recommend a “spiral curriculum” which is the introduction of oral health concepts in the basic science courses and then re-emphasizing them in the clinical setting during rotations and residency programs (Fuchs, 2008). Within the classroom, oral health could be included in classes such as microbiology, nutrition, and pathology (Fuchs, 2008).

Krol (2004) published a study that revealed “there is very little evidence to show that oral health, dental health, or some other derivative is included in medical curricula” since there have not been many studies that document research in this area (e488). Krol (2004) used the AAMC Graduation Questionnaire to assess whether oral health was regarded as an aspect included in medical and found no mention of oral health in the questionnaire. Even though he found overall inadequate oral health training in medical school, he noted that the University of Kentucky is a medical school that has incorporated oral health into its third-year curriculum and pediatric residency program (Krol, 2004). He also mentioned the University of Washington, the University of Chicago, and Duke University (Krol, 2004).

The University of Washington’s success of integrating oral health into the medical school curriculum was further elaborated in an article by Mouradian et al. (2005), in which they wrote a report which outlined the current oral health content in the medical school curriculum and other opportunities for increasing oral health material. During their assessment, they discovered that medical students at University of Washington received about two hours of oral health related material in their four years of medical school (Mouradian et al., 2005). Introduction to Clinical Medicine (ICM) was the only course that offered a lecture on oral health (Mouradian et al., 2005). For the required clinical clerkships, only the pediatric clerkships included oral health topics (Mouradian et al., 2005).

After determining the current inclusion of oral health into the medical school curriculum, Mouradian et al. (2005) identified five critical knowledge objectives for oral health: public health, caries, periodontal disease, oral cancer, and oral-systemic health interactions. Once they had developed the knowledge objectives, they outlined how to incorporate oral health subjects into required courses, include oral health electives into the curriculum, and determined a timeline for when these oral health additions would be made (Mouradian et al., 2005). The Oral and Systemic Health Theme Committee was formed in the medical school and was responsible for developing new oral health curricula (Mouradian et al., 2005). The proposed oral health elective was created and approved by the committee members (Mouradian et al., 2005). After integrating oral health into existing classes in the medical school and developing oral health electives, the University of Washington School of Medicine is now thought to be a medical school which successfully integrated oral health into the medical school curriculum.

Another program which has been successful at interdisciplinary training in medical school is Case Western Reserve University. This university is offering a five-year MD/DMD Dual degree program (Croasdale, 2007). Case West Reserve University officials believe this program is going to create a new health professional: the dentist-physician (Croasdale, 2007).

Medical Residency Programs:

Medical/Dental interdisciplinary training in residency programs is necessary to emphasize the oral health knowledge the residents learned while in the classroom. As previously mentioned, in June 2006 the ACGME mandated an inclusion of oral health education in the family medicine residency programs. Smiles for Life, an oral health module, was created to address the need for residency programs to include oral health into their programs (Douglass et al., 2009). Douglass et al. (2009) completed a study to assess the awareness of family medicine residency program directors regarding the new requirement of including oral health into their programs. They reported that 84% of program directors indicated that they were aware of the oral health requirement and 90% of the directors stated they provided instruction on oral health within their residency programs (Douglass et al., 2009). 52% of the directors noted that the residents had 1-2 hours of training on oral health and 21% of the directors indicated that the residents had 3-4 hours (Douglass et al., 2009). Douglass et al. also assessed the directors’ awareness and use of Smiles for Life and found that 74% of program directors were aware of Smiles for Life and 65% of program directors indicated using Smiles for Life within their residency programs (Douglass et al., 2009). This study demonstrated that Smiles for Life is a widely used oral health curriculum within family medicine residency programs, oral health education is minimally involved in the family medicine residency programs, and 10% of family medicine residency programs do not include oral health within their program (Douglass et al., 2009). Although having regulations on including oral health into the family medicine residency program is a significant feat, there must be further efforts made to enforce these regulations.

Although there is a requirement for family medicine residency programs to include an oral health component, the pediatric Residency Review Committee (RRC) requirements do not include oral health (Krol, 2004). To assess whether any oral health education was included in pediatric graduate medical residencies, Krol found that the Future of Pediatric Education II (FOPE II) project of the AAP surveyed pediatricians on their education during their residency programs (Krol, 2004). There were no questions regarding oral health mentioned on the surveys (Krol, 2004). Other surveys showed that the level of oral health training during pediatric residency was less than adequate (Krol, 2004). Although this article was published in May 2004 and there could be changes that have occurred since, the amount of oral health training in pediatric medicine residency programs is insufficient.

Noteworthy universities that have incorporated oral health into their residency curricula are the University of Kentucky, the University of Washington, the University of Chicago, and Duke University (Krol, 2004). The University of Kentucky has incorporated oral health into its third-year curriculum and into its pediatric residency program (Krol, 2004). The University of Washington, the University of Chicago, and Duke have all included oral health in their pediatric clerkships (Krol, 2004). Other universities that are planning to incorporate oral health in their residency programs are the University of Connecticut, the University of California, San Francisco, and New York University/Bellevue (Krol, 2004).

Expanding upon Krol’s (2004) mention of residency programs that have successfully incorporated or are planning to incorporate oral health into their programs, Gonsalves, Skelton, Smith, Hardison, & Ferretti (2004) provide a detailed account of these efforts at the University of Kentucky. The University of Kentucky College of Dentistry partnered with a few medical education sites to improve oral health knowledge through The Physicians’ Oral Health Education in Kentucky (POHEK) curriculum (Gonsalves et al., 2004). POHEK was a residents’ training program with 23 residents from the University of Kentucky and Pikeville osteopathic residency programs (Gonsalves et al., 2004). The residents attended a 16-hour didactic session and a four-hour clinical experience in the dental setting (Gonsalves et al., 2004). At the University of Kentucky, the residents work with the University of Kentucky dental faculty on a mobile dental van for two half days making dental risk assessments and applying fluoride varnish (Gonsalves et al., 2004). This training resulted in an increase of oral health knowledge and skills for the University of Kentucky residents (Gonsalves et al., 2004). After seeing the impact of the program, the University of Kentucky intended to expand this program (Gonsalves et al., 2004). Upon further research, no indicators have suggested significant expansion efforts following POHEK in 2004.

Another notable program was the Interdisciplinary Children’s Oral Health Promotion (ICOHP) project which trained family medicine residents at five community-based training programs. This program trained residents at a community residency program in Yakima, WA, Spokane, WA, Olympia, WA, and Boise, ID and a university residency program in Seattle, WA. These residency programs functioned as an intranet system, as they met regularly to discuss the program. Not only were oral health knowledge and skills integrated into the program, but a recommendation to make dental referrals was also included. Local dental practitioners were the trainers for the program and although some tension was documented between dental practitioners and medical residents, this tension appeared to diminish as they continued to work together. At the site in Yakima, WA, there was a concurrent HRSA grant which involved pediatric dental residents’ presence at the same community-based clinic. This opportunity led to pediatric dental residents working with the family medicine residents and faculty one afternoon a week. Pediatric dental residents were also involved in all didactic trainings as well. This is an exemplary interdisciplinary training as both the dental residents and medical residents were working together. 81 residents and faculty members at four sites were trained and there was a knowledge increase after the training. ICOHP provided an example of training medical residents in oral health and similar models should be reproduced in other medical residency programs throughout the nation.

Other Medical Education:

One other source of education that has allowed for the medical and dental fields to combine and work interdependently is MedEdPORTAL, which is the AAMC’s online international publication venue which allowed health educators and professionals to publish educational resources (ADEA, 2012). In 2008, the AAMC and ADEA decided to expand MedEdPortal to include dental education submissions as well (ADEA, 2012). In 2012, the ADEA and AAMC appointed Janet Guthmiller, D.D.S., Ph.D. as the new associate editor of MedEdPortal (ADEA, 2012). Her expertise within the dental field will provide a valuable resource for the new extension of MedEdPortal to include dental education resources (ADEA, 2012). The ADEA Executive Director, Richard W. Valachovic, D.M.D., M.P.H, called MedEdPortal “an invaluable resource in the dental education community” (ADEA, 2012). This resource is another educational training method that encourages interdisciplinary training.

Dental Education:

After researching information on dental education, it is apparent that most dental schools include education on general medicine. Dental school curricula include basic science classes, such as biology, anatomy and physiology, but most also include a class on general medicine.

Although medical education within dental school curricula is ubiquitous, few dental residency programs include medicine rotations. One program that does include medical education within their dental residency program is the Jersey Shore University Medical Center. As part of the Graduate Dental Education, or residency program, there is a Department of Medicine Rotation and Department of Pediatrics Rotation (Jersey Shore University Medical Center, 2013). Dental residents have found the Medicine and Pediatrics Rotations to be valuable experiences (Jersey Shore University Medical Center, 2013). The residents are under the supervision of the Director of the Department of Medicine, have the opportunities to participate in rounds with the attendings, learn about systemic illnesses and how to treat them, and learn how to perform history and physical examinations (H&Ps) (Jersey Shore University Medical Center, 2013). This program is one example of interdisciplinary training within dental residency programs.

Another dental residency program that includes medical training is the General Practice Dental Residency Program at the Mercy Medical Center (Mercy Medical Center, 2013). At this residency program, there is an emphasis on the value of the liaison between the medical and dental professions (Mercy Medical Center, 2013). This program educates residents on the relationship between dental treatment and overall health (Mercy Medical Center, 2013). The residents follow primary care patients and this opportunity provides a unique experience for dental residents (Mercy Medical Center, 2013). The Departments of Medical Education, Internal Medicine, and Family Medicine all provided support for this program (Mercy Medical Center, 2013). Based on the benefits of these programs, other dental residency programs should incorporate a medicine rotation as well.

Although the dental education already contains a component of medical education, there must be more research to integrate interdisciplinary training into the dental residency programs.

Other Interdisciplinary Training:

Interprofessional Education Collaborative (IPEC) is a newly founded national organization which will aim to focus on patient-centered care by collaborating among multiple health professionals (ADA, 2012). IPEC is composed of six national health profession associations: the ADEA, the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the AAMC, and the Association of Schools of Public Health (ADA, 2012). Although this is not specifically about medical and dental interdisciplinary training, the IPEC offers new opportunities for furthering this interdisciplinary work.

Conclusions:

Medical and dental interdisciplinary training is a recent concept within medical and dental education and therefore there are few programs that have succeeded with this new method of training. Within the medical field, the University of Washington has accomplished including oral health education into the medical school curriculum. The University of Kentucky and the University of Washington are two notable schools that have succeeded with integrating oral health into medical residency programs. Most dental schools already include general medical education into their curricula, yet there is still a need for this integration into their residency programs. The notable dental residency programs that have incorporated medicine rotations are at Mercy Medical Center and Jersey Shore University Medical Center. Further efforts to expand this integration are necessary to maximize the benefits of this collaboration.

References:

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ADEA, Five Other Associations Will Focus on Patient-Centered Care. Retrieved from

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From

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