New Buildings Support the Use of 21st Century Tools

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic looks at the role new brick and mortar facilities play in transforming learning through the use of educational technologies.

Up-to-date buildings are changing the ways we treat patients and the ways our students learn, not only in the classroom, but also in the clinic and in new preclinical labs. These new facilities retain familiar elements but hint at a substantially different future. Simulation is beginning to marginalize the traditional classroom—and even the clinic—as an educational site, and technologies developed to enhance patient care have started to transform learning.

To give you a glimpse into this future, I spoke with the deans of four dental schools. In 2006, the University of Maryland School of Dentistry (UMSOD) became the first of these four to move into a new state-of-the-art building. UMSOD left behind a dark warren of classroom and clinic spaces encased in a concrete shell—a 1970s design aimed at conserving energy. In contrast, the new facility emphasizes natural light and open spaces, prized for their social as well as visual benefits, and it incorporates a variety of educational technologies. These include lecture-capture capabilities that give students the freedom to view lectures when, where and as often as they wish. The technology also allows faculty to demonstrate techniques remotely so that rather than crowding around a demonstration station, every student has a clear view, courtesy of a video screen.

Some of UMSOD’s most dramatic innovations have occurred in the simulation lab (sim lab) and in the clinic where the use of electronic health records, digital imaging, electric hand pieces, CAD/CAM systems and, in some specialty clinics, microscopy and video capture is becoming routine. While these technologies were primarily developed to advance patient care, they are also having a profound impact on teaching and learning.

“The dilemma we have in the current clinical model of teaching is that the students generally have to stop and move away from the patient so the faculty can provide instruction,” Mark Reynolds, M.A., D.D.S., Ph.D., Interim Dean of UMSOD, told me when we spoke last month. “Streaming video from the microscope to a 32-inch monitor overcomes many teaching obstacles, allowing an attending to provide real-time feedback and instruction during the delivery of care.”

Other digital technologies in place at UMSOD are also impacting learning, and in Mark’s view, their greatest value lies in the ability they give schools to teach in the absence of patients. Take, for example, electronic health records (EHRs). These are transforming how all of the four schools I recently “visited” by phone are using their simulation labs. As John Valenza, D.D.S., Dean of The University of Texas School of Dentistry at Houston (UTSD), put it, “Students don’t just prepare plastic teeth in the simulation clinic. They treat virtual patients.”

Thanks to the introduction of networked computers at each workstation, UTSD students can access the EHRs of virtual patients as they work through simulated cases. These run the gamut from medical management to drug interactions to ethical issues, and each concludes with an intense debriefing with faculty modeled on the practice of medical educators.

Over in the patient-care clinic, the EHR continues to take center stage. “We wanted to bring the EHR into the circle of care with the patient and the provider,” John told me. “When faculty in the operatory talk with the patient and student, having the computer there to show and tell is so powerful.”

To facilitate this interaction, UTSD designed its operatories so that only one thing is attached to the dental chair: a computer with a 20″ touch screen monitor that can be drawn in close if the student wants to manipulate images while explaining a procedure or if the patient needs to sign a consent form. The monitor can also be pushed away when students need to search for information or take notes.

“We sometimes refer to the computer as the third person in the treatment room,” John said. “That can be good, or that can be bad. Some providers aren’t the strongest communicators, and having a computer in the room sometimes makes them worse.”

Carol Lefebvre, D.D.S., M.S., who was recently named Dean of the Georgia Regents University College of Dental Medicine (GRU CDM), echoed this concern. “I’ve experienced it myself when I go to my physician,” Carol told me. “They’re looking at the computer screen and entering data, and there’s no contact with me except verbally. Our students face the same issue. How do you maintain that personal connection with all that technology?”

GRU CDM moved its clinical operations to its remarkable new building in 2011, and the school is about to move its classrooms as well. It will share an Education Commons containing classrooms, simulation space and student lounges with the medical school. Like the dental schools in Texas and Maryland, GRU has also brought EHRs into its simulation lab, introduced CAD/CAM for milling crowns and restorations, and installed ceiling-mounted microscopes in its endodontic clinic.

The move to the Education Commons will allow the college to more efficiently engage in small-group, team-based learning. A tiered dental classroom has been structured with two rows of seats on each level so that students can turn around and interact with one another. A second, nontiered classroom, dedicated for use by the dental school, is wired for laptops, and large video screens will hang on each of its four walls for maximum flexibility. The room can be configured in various ways, but initially it will be arranged with tables for groups of eight to 10 students. Video from the dental operatories can be streamed into both classrooms and conference rooms. This capability will immediately allow the school to expand its continuing education courses to more practicing dentists, and may ultimately play a role in predoctoral dental education as well.

GRU CDM will also benefit from gaining access to the medical school’s many standardized patients in a simulation area of the Education Commons dedicated to interprofessional education. In this space, design may play a bigger role than technology. Two large open bays with beds that can be curtained off line the walls, and tables in the center of the room give students from different professions a place to congregate while they develop diagnoses and treatment plans. An additional 24 single-patient examination rooms provide separate areas to observe patient and student interactions.

Carol expressed excitement about the opportunity GRU students have to become skilled in using the latest technologies, but she raised interesting questions about how they will transfer these abilities to the practice arena.

“These technologies—CAD/CAM units, intraoral scanners, digital radiography, microscopes—are very expensive for private practitioners. There are still practices that are using film,” she observed. “As educators, we have to find a balance. We have to expose students to all these technologies, but we have to also teach them traditional methods.”

Finding this balance will be one of Carol’s mantras as GRU CDM embarks on its first significant curriculum reform in 10 years.

Meanwhile, back in Maryland, UMSOD is preparing to take the next step in its digital dentistry adventure: harnessing the technologies it has in place to radically change how clinical skills are taught and assessed. CAD/CAM currently allows users to convert an intraoral photo into a 3-D rendering that can be used to design a dental prosthesis. Three-dimensional images of the prosthesis can then be sent wirelessly to a milling machine, as occurs at UMSOD, or to a 3-D printer, either of which can fabricate the finished product.

Soon the school expects to acquire an evaluation program, which will work within the CAD/CAM system. The software can consistently and reliably scan a student’s tooth preparation and compare it to a faculty-determined standardized preparation, allowing students to evaluate their own performances. As Mark Reynolds pointed out, the software will enable an iterative process of learning through which students can systematically perfect their clinical skills.

John Valenza expressed similar enthusiasm for using software to assess students, but for different reasons.

“These new technologies will enable us to redefine the metrics we use for assessment,” he asserted, “and they are independent of clinical judgment.”

Indeed, computers have the potential to evaluate student work in a way that is consistent, reliable and unquestionably objective. Computer-assisted evaluation would obviate the need for faculty calibration (at least in the areas that lend themselves to digital assessment). With its potential to reduce some of the burden of grading, this type of evaluation should be especially welcome at schools where faculty are stretched thin.

Even where faculty are plentiful, the use of digital technologies can enhance assessment. At UTSD, for instance, John Valenza has observed that the simulation clinic—by providing a consistent experience to students—has had an unintended benefit.

“It is a fabulous way to calibrate faculty,” he told me. “They collaborate to build and deliver the cases, and every student in the class takes part in the simulation exercise. Whether the focus is on standards of care, materials or a medical management question, it puts everyone on the same page.”

Miles away on the West Coast, I had the opportunity to attend the ribbon cutting for the new University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific Dugoni) building in downtown San Francisco earlier this month. As in Maryland, Pacific Dugoni’s new building emphasizes community spirit and more open space where faculty, staff and students can come together. No one has private offices, including the dean, although private rooms are available for private conversations. Not surprisingly, the new facility will have fewer large classrooms and more networked spaces where students and faculty can access technology to engage in case-related learning.

“We have multiple goals for the building,” Dean Pat Ferrillo, D.D.S., told me. “We want to create flexibility, a new learning environment and a new practice model, as well as a sense of community, and finally to move much closer to our patient population. We know the technology is going to be a major part of learning for the next generations. We need to be sure we have the “infostructure” to support what we know today and what we don’t know about tomorrow.”

The centerpiece of Pacific Dugoni’s new facility is a state-of-the-art simulation lab. Its operatories, like those in several other newly built or renovated schools, will precisely replicate those that students will find in private practice. The space will also house a new generation of mannequin that exhibits more life-like facial features, a full tongue, saliva flow and anatomically correct teeth. Pacific Dugoni developed the mannequin head in partnership with its manufacturer, KaVo Kerr Group, to give students the feeling that they are treating human beings when they practice on the mannequins rather than simply preparing plastic teeth.

The innovations taking place at these four schools and at many other ADEA member institutions are truly impressive. Yet in the end, technology is a tool—a means to an end—and it is not the only tool in the toolbox. The open designs that foster collaboration at Pacific Dugoni and at UMSOD, the opportunity to work interprofessionally at GRU CDM and the intense debriefing with faculty following simulation at UTSD all underscore the importance of other factors in achieving our educational goals.

That said, time has shown again and again that technologies that appear optional today often become essential in the future. Can we still teach without them? Of course, but those schools on the cutting edge will be better positioned to meet the next wave of innovation when it arrives.

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