By Colson Smith
Leading up to our first appointment in clinic, one of my classmates asked our supervising dentist a very insightful question. “What do we tell our patients when they ask if we’ve ever done this on a live patient before?” The professor thought for a moment and replied, “Tell them you’ve done a number of these procedures… after all, zero is a number.” While this response served to lighten the mood, it also touched on something very important. Patients care about how much experience their clinician has. Patients want their dentist to have done whatever they’re doing a number of times! Nobody wants to be someone’s first crown, first filling, or first root canal. People implicitly trust experience. Likewise, people distrust inexperience. This doesn’t just apply to dentistry. People instinctively trust someone with a good track record. It’s why you look for a little bit of gray hair when you go to someone for life advice. Your first few months in clinic you might not be able to boast in your experience, but by graduation you should be able to announce confidently to your patients that you have, in fact, done a number of every procedure. This is where clinical requirements come in to play.
When evaluating dental schools, one of the biggest distinguishing factors is the amount of clinical experience you receive in your education. To ensure students graduating from a particular institution have a baseline skill level, schools have requirements. “Requirements” is a dental school term referring to a certain number of procedures that must be completed in order for a student to graduate. Most schools have requirements for the full gamut of basic procedures: crowns, fillings, extractions, root canals, dentures, removable partial dentures, and scaling/root planing. The numbers of procedures vary so much school-to-school that it is not worth trying to give an average. One of the best ways to find out the exact number of requirements dictated by each school is to ask a third or fourth year student at the school. Any student currently working on fulfilling these requirements will be acutely aware of the number. Another great way is to ask on a forum or search existing forums. In fact, there is a great thread on Student Doctor Network regarding this very topic. If experience is important to you, clinical requirements should be one of the leading factors in your decision of where to attend dental school. Even if it’s not that important to you at the moment, I can guarantee it will be important to your future patients. Truth be told, that will probably be the only component of your time in dental school that the majority of your patients will care about.
If you’ve heard anyone talk about clinical requirements before, it’s possible there was a negative connotation attached to the term. Students tend to begrudge them. There are certainly aspects of requirements that are worth begrudging. However, clinical requirements have been the gold standard in dental patient care education for eons. They are a tried and true method for producing competent dentists. There is probably no perfect way to train a clinician, but requirements remain the staple for now. It’s worth discussing the pros and cons to requirements, as well as some ethical considerations attached to them.
The pros of a requirements-based system are pretty straightforward. The best way for a student to demonstrate they are competent in a procedure is to have amassed a number of completed procedures. There are few metrics that are as telling of your expertise as the number of procedures you have performed. The number does not prove that you are excellent, but rather experienced. By establishing a requirements-based system, schools ensure that every practicing dentist that enters the workforce reaches a certain threshold of supervised experience. It is also helpful for students to assess how they are progressing toward their graduation requirements. There is no ambiguity with numbers. Twenty crowns equals twenty crowns. The school’s expectations are easily communicated and students are left without questions of what is demanded of them in clinic.
The downsides of requirements are more often discussed than the upside. Students often complain about requirements for several reasons. The first (and worst) reason is that they can be hard to complete. The challenge of requirements is the foundation for many of the complaints about requirements. Dental school is not supposed to be easy, so go ahead and throw this excuse out the window. The other shortcomings are more well founded and deal with questions of professional ethics.
The ethical concerns about numerical procedural requirements have been a hot topic in dental education for at least the last 10 years. The primary ethical argument against a requirements-based system is that it is not patient-centered. It is said to promote production-centered treatment rather than patient-centered treatment. Out of necessity, students become so focused on the number of procedures they have to complete that it is easy to lose track of the patient’s overall needs. It can produce the mindset that patients are a means to an end rather than the end themselves. Often times, patients are bounced around from student to student for the completion of different procedures. Continuity of care is disrupted by the supreme need for completion of requirements. The farthest-reaching ethical concerns even include the potential for overtreatment. The thought is that if a student is desperate for requirements it produces an undue temptation to over diagnose. Again, these concerns are extreme. The dental profession is exceptionally ethical, and schools would not have systems in place that they felt violated these high standards.
For those who dislike requirements, there is good news. Alternatives to requirements have begun to emerge. One such alternative is the case completion curriculum. This clinical education model shifts the emphasis from number of procedures to completion of individual patient cases. In theory, this helps develop practitioners that are more focused on patients’ individual needs than on production numbers. The schools that have implemented such systems have noted a dramatic increase in the number of completed patient treatment plans per student dentist. The acclaim of this model is that it is patient-centered. The criticism of this model is that it is more convoluted and difficult to calibrate. Schools that have taken on this approach have had to implement case classification systems in an attempt to distribute patient cases evenly among students.
Schools across the country have gone to great efforts to make clinical care more comprehensive and patient-centered. Some have found ways to do so by keeping numerical procedural requirements, while others have abandoned the system altogether. By and large, clinical requirements still dominate the dental education landscape.
Regardless of the system, the important thing is that schools prepare student dentists for patient care with hands on practice. Students should see high clinical requirements as an opportunity, rather than an unwarranted burden. Clinical requirements offer a chance to gain critical experience while under supervision. The more dental care students can provide while in school, the better prepared they will be to provide exceptional care upon graduation. After all, we all want to be able to look a patient in the eyes and earnestly say that what we are about to do we have done a number of times.
About the Author
Colson Smith is a fourth-year dental student at the University of Alabama Birmingham School of Dentistry. He is an avid outdoorsman and enjoys spending time outside with his friends, family, and three-year-old black lab.