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These past few weeks I’ve been spending some time with our junior class in clinic. I did this mostly for personal reasons (finding a board patient, completing an assignment, gathering local anesthesia hours, etc.) but also to just help out and get a better feel of what it’s like to be a clinical instructor. 

One incident stands out in my mind. I was tasked with helping a junior student take intra-oral photographs to use for her case documentation assignment. The juniors had not received instruction on how to use the camera, what items they need to check out to take the pictures, what the pictures should look like, the whole she-bang. Completely clueless. I tried to teach her how to do things the best that I could, considering our time constraints. I felt a little frustrated and huffy because she didn’t know anything and I thought that having her take the photographs that day wasn’t  appropriate,  given her complete lack of education on the subject.

I thought that I had an abundance of patience, but on that day, I found that I still need to work on that. Because we were rushed, I missed out on going very in-depth as to why we take the pictures, what each one should look like, how to operate and troubleshoot the equipment, and some of the finer points of intra-oral photography. The junior missed out on this opportunity, and it’s partially my fault. This is very unfortunate because I have a lot of useful information to share, can share it in an easily understandable way, and can deliver it with an upbeat attitude. The patience part is where I was lacking that day.

That day was not an isolated incident, however. There have been other interactions where more patience on my part would have benefited the student. For example, a student left their patient’s chart open on the counter, unattended. In our clinics, this is a violation of HIPAA, which we take very seriously. I thought that closing our charts had been ground into our heads enough that this wouldn’t be a problem after a month in clinic, but apparently it hasn’t (can you see the “sass” coming out with the words that I type?) So this “sass” isn’t beneficial to the students, and if I said the previous sentence to a student’s face, there would be problems. I have the patience of a saint with my patients, but it turns out that I don’t have that with other students. If I work on this more, it would help me become a better clinical instructor. I don’t know when the next time I’ll be able to play “teacher” is, but I’ll make sure to remember to have more patience next time around.

-HH

The scenario: I was just offered a clinical teaching position in a dental hygiene program. What more do I want to know?

First, I’d want to know what would be expected of me as a faculty member. Do I have to administer competencies, do I get the final word on those, do I have to act as a faculty advisor for students, am I expected to participate in research, how many hours a week will I work and if the schedule is fixed or flexible, is my attendance expected at meetings, etc. All this information would help me see where my boundaries were and how I would fit into the program itself. It’s good to know what all your responsibilities are so that you don’t miss something and have it negatively effect the students and possibly put your job on the line.

Secondly, I’d want to know about the program’s academic policies and the policies of the institution. This is important because if I were to not follow the policies, a situation where legal action is taken against me could arise. I would also ask them if they have any guidelines for those situations, and whether or not I would be standing alone or would receive help from the institution in terms of legal counsel or malpractice insurance. This information would help me form an emergency plan, and keep my actions in line with the policies. I would also memorize the portion of the state board professional practice act that outlines the regulations for students. This would let me know what actions or activities are legal for the students to participate in and what my role in those activities should be. You always want to stay within your scope of practice, especially when students are around, because they could see you doing something illegal and want to try it themselves. That would also reflect negatively on the school and profession as a whole. Word could go out through the student grapevine that sometimes Ms. H will extract extremely loose teeth on purpose and sometimes she’ll let the students have a go at it. If that information falls into the hands of anyone that cares to follow up on it, then Ms. H is in big trouble, and rightfully so.

-HH

To me, having diversity means having people from all walks of life. When people speak about diversity, they usually focus on race and gender, as those categories are easiest to put people into. However, we can also look at age, socioeconomic status, sexual orientation, and cultural backgrounds. These are all factors that play into how a person communicates, their health beliefs, and their attitudes towards various ideas.

Dental hygiene in the United States is mainly populated by straight, white, middle class women. I think this is mostly due to the kinds of people that are exposed to the profession at a younger age. I would be willing to bet that the overwhelming majority of hygienists have always had access to dental care and had a female family member or close friend that turned them onto the profession. When I was shadowing hygienists before I got into the program, many of them mentioned that dental hygiene is a great profession for women, their reasons mainly having to do with taking time off to birth their children. Flexibility with managing children’s activities have also been brought up frequently. The issues with dealing with children are certainly a big bonus for women who want to balance a career and a full family life, since women are still generally the primary caretakers of children in our society. The initial knowledge of the profession, the flexibility it offers, and the ability to afford the education are the major factors that draw middle class white women to dental hygiene.

Please make it stop.

Much of the underserved population is made of minorities and/or people of low socioeconomic status, so if these people aren’t seeing dental hygienists, then they don’t know that the profession exists. If you don’t know that something exists, then how can you entertain the thought of pursuing it? I briefly saw a dentist two times while I was a minor, and was 21 before I encountered a dental hygienist, and had no idea the profession existed. I knew what a nurse did, what a teacher did, and what a hair stylist did, and thought of pursuing those careers before I discovered dental hygiene on my own through a chance meeting and some research. Then later, a government program provided my college tuition, enabling me to pursue my dreams.

Having a diverse workforce is ideal because different people bring different things to the table. A viewpoint not considered before, an idea, a new way to approach a problem. Each person views the world from a unique perspective, which holds the possibility for improvement.

The cost of tuition is definitely a prohibitive factor. This is such an extremely large issue with colleges nationwide that I can’t even begin to explain all the problems. Just know that the cost of tuition keeps education out of the hands of many people that truly desire it.

If more people had better access to care, then I think the diversity of the profession would increase naturally. This would be a long-term investment in the future of the profession, and would require a lot of work and the collaboration of not only dental personnel, but medical and social workers too. I’m not a fan of forced diversity – meeting quotas and filling slots with candidates that may or may not be the best qualified, all for the sake of “diversity”. Many times, this practice actually harms the workplace and can breed resentment. If dental hygienists could reach more people, not only would this improve the overall oral health of the population, but it would also gain us exposure and attract different kinds of people. It’s a win-win situation. There’s nothing about dental hygiene that makes it more suitable for white women, just like there’s nothing about engineering that makes it inherently better for men. Clinical dental hygiene requires good critical thinking skills, interpersonal skills, and hand-eye coordination. With a good teacher, some practice, and a heaping plate of dedication, anyone could be a dental hygienist.

-HH

Both the article and the study brought some things to light that I’ve never thought of before. I didn’t think the sequence of exploring mattered so much. I personally never looked at the order in which an instructor went around a patient’s mouth – I didn’t think it mattered. When I saw an instructor exploring quickly, I just thought they were more experienced so they were “allowed” to go quickly, and figured I would get there one day too. The article mentions the students watching the instructor’s technique and drawing conclusions about the level of fairness of the evaluation from it. If all instructors use the same exploring technique, then the student is more likely to believe the instructor’s results because the process has been standardized. On the flip side, the study found that calibration training did not end with more agreement between instructors about actual calculus detection. Previous studies have found that only with long-term intensive training does inter-examiner reliability actually increase.

Going off of just these two documents, it is safe to assume that faculty calibration only changes the appearance of calibration to the students, which would lead to improved student perceptions of calibration without actually increasing inter-examiner reliability. The student perceives fairness, and gives feedback appropriately. At the end of the day, the feedback from the students is the driving force behind the question of whether or not faculty calibration is needed.

EDIT FOR CLARITY:

When I’m talking about calibration here, I’m talking solely about calibration on calculus detection procedures and perceptions. Other areas of clinical instruction such as information about due dates, assignments, policies and etc. should never be up for argument and the instructors need to always be on the same page. End of edit.

Obviously all hygienists practice a little differently from each other due to their previous clinical experiences and the way that they were taught in school. Old habits can be hard to unlearn, but the process of calculus detection can be standardized. However, what counts as calculus can be very subjective with much disagreement between even experienced individuals. Due to human subjects being involved, the nature of calculus cannot be standardized. It would take everyone across the country to learn what calculus feels like on the same patients, which is not feasible and never will be. Woe is us, huh?

-HH

The purpose of this post is to record my thoughts and reactions to and about some of the current dental hygiene accreditation standards.

In section 3-7 of the ADA Accreditation Standards document, there contained an item that surprised me a little. It listed “scholarly productivity” as an example of a way to comply with the document. Scholarly productivity can include activities such as participating in research, publishing a paper, etc. I always thought that this kind of activity was just a good suggestion, to be viewed as something that would advance the faculty’s knowledge and academic standing, not as something that would satisfy an accreditation requirement.

Section 4-1 covers the clinical facilities provided to students. I’m mostly interested in the subsection 4-1.a, which says: “The dental hygiene facilities must include the following:

a) sufficient clinical facility with clinical stations for students including
conveniently located hand washing sinks and view boxes and/or computer
monitors; a working space for the patient’s record adjacent to units; functional,
modern equipment; an area that accommodates a full range of operator
movement and opportunity for proper instructor supervision”

I’m digging the floral fabric, though.

I think these items are very worthwhile, and can definitely have an impact on the student’s time in clinic, be it negative or positive. It made me think about our clinic facilities at school and how they technically follow this guideline, but the spirit is lacking in some circumstances. For example, I am the only left-handed student in the hygiene program right now. The entire student hygiene clinic is geared towards solely right-handed operators, but I can usually modify the set-ups to where they can reasonably meet my needs. It’s not ideal, what with all the back twisting, bracket tables turned backwards, and awkward arm positions (maybe that’s why my body hurts so much). In this situation, the school is following the letter of the law, but not quite the spirit.

In the Core Competencies document, I was surprised to read CM.5, which said “Evaluate reimbursement mechanisms and their impact on the patient’s/client’s access to oral health care.” The first thing that came to my mind was patients with Medicaid. One prophylaxis is covered per year, and many of the patients are unwilling to pay out of pocket for further appointments. This is not ideal, but it is a reality. They also have a $3 co-pay for each visit, which also affects the patient’s willingness to schedule appointments. This kind of information was taught to us in school more as a little tip or insight, not as a core competency. I had no idea something like this could be listed as a competency.

In the same document, I thought the inclusion of PC.3.d was interesting. It reads “Make referrals to other health care professionals.” Much like the previous Competencies item, I thought this was more like a favor to do for the patient, or a little tidbit that would improve the care you provide. Most of the patients that come to us in our student clinics have established medical issues, so we don’t have many opportunities to recognize a new issue in our patients. However, most of us will work in a private practice setting where the patients tend to be less complicated. We’ll also be able to form better relationships with our patients, since we’ll likely be seeing them more than twice. In this situation, the ability to identify possible medical issues needing assessment  by a primary care physician will be invaluable to our practice. I’m glad this is included in the Core Competencies because it shows that dental hygienists are capable of recognizing systemic health risks.

-HH

For the situation with Mary, the first thing we should think about is the safety of the patient. I would ask her about the medications the patient was taking, and if there was anything to add to the list. If she simply forgot to mention the pre-med, this would give her an opportunity to remember it. If she just forgot to tell me about the pre-med, I’d give her what we here at OSU call a “below expectations” for the medical history portion. Everyone has a “brain fart” now and again, but pre-med situations are not something to be taken lightly, as they have the possibility to turn into a large problem for the patient, and legally, the practitioner. I would tell her that I recognize that this is out of character for her, then remind Mary of the gravity of the situation, and encourage her to make it a point to verbalize the patient’s pre-med status immediately upon presenting the medical history to the instructor. When giving feedback, it’s important to let the student know that you’re familiar with the way they usually handle themselves in clinic because it shows that you’ve been directly observing them. This lends credibility to your words. 

With Ben, I would give him the benefit of the doubt at first. Since I’m rushed and maybe not feeling my best, it’s quite possible that my calculus detection skills took a nosedive that morning. I’d slow down and recheck, and if I still came up with that much calculus, I’d ask him to re-explore. If he still came up with nothing, then it would become apparent that his exploring skills need revisited, which could be why his self-assessment was so off.  I could ask him to show me how he explored around those missed areas in order to see what went wrong, and help him correct his technique right then and there. Instead of giving him a below for the day with no further explanation after the clinic session, it’s better to provide immediate feedback because everything is still fresh in the student and instructor’s heads. If, for example, Ben wasn’t dropping into the col all the way, causing him to miss calculus, I could put the explorer in my hand and show him what it looks like in the mouth when the instrument is all the way in. Showing the student examples of the correct way to do something helps them learn and modify their approach, and also gives them a picture of what to strive for in the future. As far as grades go, I would also give him a “below expectations” for the missed calculus, which then led to an inaccurate self assessment.  The self assessment portion is important as well because it can reveal a student’s thought process and any misconceptions that they might have about a given topic. The point of self assessing is to identify areas to improve upon. If the student is unable to do this, they will be more likely to see themselves as irreproachable and become unresponsive to feedback, which we know plays a vital role in learning.

-HH

Questions:

1. Should students know they are being evaluated? Why or why not?
2. Should students have to pass competencies more than once? Why or why not?
3. What strategies could instructors use to help students who are incredibly nervous during a competency exam?

Response:

Long story short, I don’t think students should always know when they’re being evaluated. I have a crazy idea, hear me out. In our clinics, competencies are always scheduled in some way. In pre-clinic, we all had days assigned to us to complete certain competencies. Then when we got into clinic and in our senior year, we would have to approach an instructor to let them know that we’d like to complete a competency during that clinic session. By scheduling the competencies, the student can review the criteria and any questions they might be asked, and can give themselves time to fully prepare and seek any remediation training prior to the testing. I think students generally like this aspect of testing because they know what is expected of them and when it is expected. Therein lies the problem though. This approach is good for the first round of testing, but for after that, don’t we want our students to be able to demonstrate competency at all times?

During clinic sessions, after assessments have been checked in, the instructors generally find an empty cubicle to camp out in and wait for students to approach them for their scaling checkout. While we are scaling, it’s unusual to have an instructor come over to just observe, and when they do, we get nervous and think we must be doing something wrong to warrant the attention because instructors are usually only present for instrument competencies during that stretch of treatment. My idea is to have the instructors float around during scaling and observe more frequently, thereby normalizing the presence of the instructor during non-assessment times. This way of operation could be introduced to students at the beginning of their clinical experience, so it would be a normal thing to have an instructor wandering around. The instructor should also make their presence known to the student. There have been a few times when, out of the corner of my eye, I’ve noticed an instructor sneakily peeping at me, and it makes me feel even more uneasy than if they were standing right next to the patient.

So if the instructors are generally present, this would give them the opportunity to conduct assessments on the student, which could be a combination of graded and ungraded. If the students didn’t know which assessments were to be graded, it would force them to be on their best behavior at all times. Some students might not like this,  but these are probably the students that need the most help and would benefit the most from the assessments. After an ungraded assessment, the instructor could immediately provide feedback for the student in the areas they need to improve in.

By having the instructor in the cubicle more, this would help the student become more comfortable with their presence and decrease testing anxiety. There have been a few times when an instructor has come over to watch me and I have just frozen dead in my tracks. I’d fiddle with my instruments and explore a little before picking up my favorite instrument to demonstrate proficiency until they left. Outside of dental hygiene school, I perform very well under stress. In clinic though, I turn into an anxiety monster laden with worry and stress. One time during a pre-clinic competency, I had a full blown anxiety attack, which was an extremely unpleasant and brand new experience for me. I think changing the testing environment like I spoke about previously would help reduce student anxiety immensely. As far as things instructors say during episodes of anxiety, my instructors would often say things like “It’s ok” “You’ll be fine” “Let’s just do it” and my favorites, “It’s not the end of the world” and “It’s not a big deal.” The first two are fine, but I don’t like the last two. While it’s true that it’s not the end of the world, saying that is marginalizing the student’s thoughts and feelings about the situation. “It’s not a big deal” goes against everything the syllabus says, which leads to more confusion and discomfort for the student. We as students trust that the syllabus is accurate, and if it says a student can’t advance in clinic if they fail the competency, then of course that could lead to some anxiety. Instead of downplaying the student’s fears, the instructor could say that it’s ok if the student is feeling anxious and it happens to a lot of students, it’s a common occurrence and the student shouldn’t feel bad for feeling anxious. Sometimes an anxious student can feel like they’re the only one having a problem, which in turn makes them worry more about being anxious and makes it easier for them to lose focus on the task at hand. It’s good to acknowledge the student’s fears and encourage them to work around it, and to not show frustration with the student. If the instructor is a little huffy and obviously just wants to get the test done, the student can pick up on that and it’d only make the student feel worse. I’d say “It’s ok that you’re feeling anxious, this is important to you and you have a good reason to feel the way you do, but I want you to try and focus on the instrument right now. Let’s work around your anxiety and try to not let it get in your way right now.”

As far as how many times a student should be evaluated, I think more than once is good but no more than three times. We had a set of competencies in pre-clinic, one in our first semester of clinic, one in the beginning of our senior year, and another our last semester. That makes four sets, and most of my classmates agree with me when I say that it’s a bit ridiculous. After a certain point, we stopped viewing them as useful and more as a burden, something to check off a list, which negates their intended purpose. The set in pre-clinic is important, because the student needs to be able to treat patients effectively. The second set in clinic proved to be a major stressor, especially with the deadline that we had, but I think it served well to lock down our skills. I think the third and fourth sets were largely useless and mostly served to soak up our precious, precious time. Deficiencies could be identified by the newly present instructors and approached on an individual basis, instead of having more tests for the entire class. I think it would be a better use of everyone’s time and efforts.

-HH

Question: Should clinical faculty only reinforce what is taught in classes or textbooks? Do these modifications have a place in clinical teaching? How could a clinical faculty member introduce different techniques without negating what students were taught in the classroom or pre-clinic?

Response: I do not think that faculty should only reinforce what’s taught in school. Different techniques and modifications should be taught as well, but only under certain conditions. After a student has mastered the skills taught from classes and books, they should be taught some alternative methods as well, in order to increase their skillset and further their professional development. By mastering the basics, this shows that they are ready to move on and learn more. Have you ever heard “We have to learn to walk before we can run”? This quote applies to this kind of situation. For example, in order to use a 204S on anterior teeth (alternative instrumentation), the student first needs to know how to get the right angulation with that instrument.

It’s important to have the fundamental skills down first, because alternative methods won’t always be the best option and a person needs to have something to fall back on. It should be made clear to the student that the alternative methods are in no way permanent replacements for the basics. Another quote comes to mind here, “If you just learn the tricks, you’ll never learn the trade.” It’s also important to keep an eye on your own actions when a student is present. If they see you using a technique that they haven’t been taught yet, they might want to try it themselves before they’re ready. The students will always be watching you no matter what, so you have to be mindful of your own actions.

Teaching alternative techniques also gives the faculty member the opportunity to use some coaching techniques. Let’s say a patient can’t open their mouth very wide, making it hard for the student to get a good intra-oral fulcrum. By using the educate technique, the faculty member could introduce an extra-oral fulcrum.This would increase the student’s skill and confidence levels. When the student is in a similar situation in the future, they would then have another tool in their toolbox to use when the basics aren’t good enough. This situation would also be a great time to use the encourage coaching technique. By gently guiding the student through learning the new skill and reaffirming their actions, the student would gain confidence and be more willing to use the new technique in the future. It’s amazing what a simple “Hooray you did it! Great job!” can do for a student.

-HH

Situation: While checking in the intra/extra oral exam you notice a lesion on the buccal mucosa. The student has not mentioned it to you and you have not looked at the intra/extra oral exam page yet. What question do you ask and why do you ask that question? What follow up questions might you ask? Remember to follow the principles introduced in the readings and discuss how your questions follow those principles.

Response: Before beginning to see patients in clinic, our students here are instructed on normal oral anatomy, common pathologies,  and given some basic instructions on how to report and record something out of the ordinary in the patient’s mouth. I expect this information is taught in all pre-clinic courses. In our program we start seeing patients the last half of our junior year, but don’t take the pathology course until our first semester of senior year, where we really get into the nitty gritty of identifying lesions. It was said in HCT Ch. 5 and elsewhere in our coursework that it’s important to know where your student is at in their studies, in order to get a feel for what to expect out of them. I’d first ask the student if there was anything special about the intra/extra oral exam that they’d like to bring to my attention. If the student did indeed find the lesion but just forgot to mention it right away, this would give them the opportunity to tell me and would also remind them to bring up items of note without me having to discover them on my own. Like Ms. Henry said in the lecture, simply asking the student if they saw the lesion would lead to a yes/no response, leaving no opportunity for some better lead-in questions.

If the student did find the lesion, I’d ask them to tell me about it. Hopefully they would cover location, size, and appearance, since those are the very basic steps to take in this situation. If they couldn’t tell me about the lesion, I could remind them of the basic steps and have the student get back into the patient’s mouth so they can examine and describe it themselves. If I just told the student the lesion’s description, then the student wouldn’t get that practice, which they obviously need. This would also have the student go through the first three levels of Bloom’s Taxonomy-knowledge, comprehension, and application.

Next we’d talk about what the lesion could have been caused by. This would involve the next step up Bloom’s Taxonomy, analysis. I’d ask the student if they knew what the lesion was or was caused by. If they do, I’d ask them to explain their reasoning so I could see their thought process, and see if they asked the patient the appropriate follow-up questions. I could then ask them “Why do we want to know how long the lesion has been there?” or “Why do we care how big the lesion is?” to help them connect the facts to the reasoning behind the question. I could also then ask “Does this lesion cause concern?” and if it didn’t, I could then ask “What would raise some red flags?” to help the student think about those things and contrast them to the current situation. Starting with easy questions (describe the lesion) and moving up the chain to more difficult (why do we not need a path consult?) is a method of questioning called scaffolding, or laddering, that is a great method to use in these kinds of situations.

-HH

Critical thinking is an important skill that can be hard to acquire because it’s not something that can explicitly be taught.  The preceptor handbook mentions that a good strategy to teach critical thinking is through your own questioning techniques, and through good role modeling. The kinds of questions you ask a student can help them pick apart their own thinking, and also the student will be given an idea of what pieces of information are most important by listening to what kinds of questions the instructor asks. The conversation on page 25 of the Preceptor Handbook is a great example of how to discreetly teach critical thinking through your own questioning techniques. Instead of simply accepting the student’s diagnosis and telling them the next step, it’s better to ask  questions about how the student came to their conclusion and what factors went into their decision. My instructors do this with me when I tell them how many/what type of films I want to expose with a patient, and when I tell them the patient’s AAP classification. It forces me to pull together my knowledge and present it in a logical manner instead of just making a guess and being correct and not subject to further investigation. This approach of picking apart an answer is a valuable activity to teach critical thinking, and I will definitely use this practice in the future. After reading through the Preceptor Handbook, I recognized many of the coaching techniques as interactions that I’ve had with my own instructors in clinic. For example, my instructors have encouraged me after I completed care on a difficult patient, and  have counseled me when something unsavory happened. I plan on using all of these techniques with my future students.

In dental hygiene, I think teaching facts is just as important as teaching critical thinking. I liken it to building a house, where the bricks are the facts and putting the bricks together to form a house is critical thinking. You can’t have one without the other. For a more specific example, I might be able to complete periodontal assessments, but I also need to be able to pull the results together in order to tell my patients definitively that they have gingivitis or moderate periodontitis, etc. and be able to defend my decision. Sometimes we will be presented with a complicated case where there are no clear answers, in a book or elsewhere. During times like these, critical thinking skills must be utilized in order to solve problems and provide efficient care. In Article B, John Dewey described the reflective judgement process as “Identify the issues and facts in a problem or dilemma, identify and explore causal factors, retrieve and assess knowledge needed to appraise response options and guide actions, compare the strengths and limitations of options, skillfully implement the option most likely to resolve the problem, monitor implementation and outcomes and modify the strategy/action as needed, candidly appraise the outcomes of actions, both positively and negatively.” This approach can at first be facilitated by clinical faculty to show the students how to fully appraise a situation and what steps they need to take to approach solving the problem. Later on, the student can remember this process and use it to solve a problem when the instructor isn’t there to walk them through the process. This is important because once students graduate and get out into the real world, there might not be someone near them that can answer their questions, so they need to be able to figure things out for themselves.

Now let’s look at a quote. “Education is what remains after one has forgotten what one has learned in school.” -Albert Einstein

Do I agree with this quote? Yes, yes I do. I’ve heard numerous people describe their most influential college professor, and being taught how to think is brought up frequently. They’ve said that facts are nice and all, but being taught how to think affected their lives in a much bigger, positive way. Critical thinking skills aren’t pushed in every education track or major, which is unfortunate because having those skills help not only in an academic setting, but can also be used in your personal life to help you make decisions in unfamiliar situations. Someone could use these skills to decide which city to move to, which fridge to buy, which articles to believe, etc. Instead of just looking at the facts and basing a decision off of those, critical thinking skills would help the person elaborate on and connect those facts to put together the bigger picture.

-HH