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Teachable moments in the dental clinic are rare and are not adequately exploited. Students often ask simple procedural questions, such as “What should I do next?” A preferred approach is one in which the clinic preceptor helps the dental student collect data about the patient’s condition, analyze the data, and consider scientific evidence and the patient’s profile in the formulation of diagnoses and treatment plans. The School of Dentistry at Oregon Health & Science University modified the one-minute preceptor method that was developed to instruct medical students in clinical office settings, using the acronym iCARE, which is an abbreviation for microskills that the dental preceptor and student follow when interacting in a dental clinic setting. From the preceptor’s perspective, iCARE stands for Inquire, Cultivate, Advise, Reinforce, and Empower; from the student’s perspective, iCARE is Initiate, Contribute, Apply, Reflect, and Execute. iCARE enhances the value achieved in preceptor and student interactions, promotes the student’s critical thinking, and encourages the student’s use of scientific evidence in formulating and supporting patient care decisions in the clinic.
The brevity of teachable moments in a dental clinic setting1,2 is complicated by the relationships and expectations of the dental student, clinical instructor, and patient. In an effort to involve the patient, the discussion between instructor and student often occurs chair-side, making critical feedback to the student difficult and awkward. In discussions with the clinical instructor, the dental student may provide incomplete information about the patient’s condition for the instructor to evaluate the student’s tentative diagnosis and treatment plan. The dental student may also be inadequately prepared to conduct a meaningful conversation with the instructor. The instructor, as the dental preceptor, may quickly ask the dental student questions about the patient’s condition in order to make a fast assessment of the patient’s dental condition and formulate instructions for the next action.
The interaction between student and instructor may often consist of short, student-initiated procedural questions, such as “What should I do next?” The dental preceptor may quickly respond to the dental student’s question with specific instructions, then move to the next student, repeating this process. The clinic instructor, faced with responsibilities to supervise several dental students without sufficient time, may control the exchange, speak too much, too quickly, too abruptly, and perhaps too condescendingly or too patronizingly to the dental student.3 The dental student does not want to be embarrassed or humiliated and does not want to be made uncomfortable in front of the patient. The student also does not want the patient to feel uncomfortable and less confident in the quality of care. The student wants to be taught what is needed to care for the current patient, wants to be valued for existing skills and knowledge, and wants to be regarded as an equal partner in the health team.4
A goal of the clinic experience, from both the instructor’s and the dental student’s perspectives, is to help the student learn to gather and analyze critical facts, assess the patient’s condition, arrive at a tentative diagnosis, and determine a treatment plan and course of action. Therefore, the exchange between the instructor and the student needs to be professional and needs to draw the patient into the exchange. The dental student should draw from the instructor’s knowledge and experience, rather than merely relying on the instructor to be a gatekeeper and checker, and the dental student should manage the care of the patient. The instructor should share knowledge and mentor, for both the student and the patient’s benefit. This is best achieved in a respectful, positive environment, in which the instructor and student are both prepared to engage in a professional and constructive discussion in front of the patient. The instructor and dental student should work as a professional team to critically analyze evidence, design a strategy for care, and exchange information in collaboration with the patient.
In medicine, various approaches to facilitating the medical preceptor and the student’s exchange of information efficiently and respectfully have been offered.2,5 In particular, the one-minute preceptor approach, introduced by Neher et al. in 1992,2 has received much attention as a communication framework that helps the medical student learn problem-solving skills while presenting cases to the medical preceptor. This article describes the application of the one-minute preceptor approach to instruction in the dental clinic. Similar to the medical approach, the dental framework facilitates a professional exchange of information between the clinic instructor and the dental student, while educating the student and providing the best possible care for the patient.
The one-minute preceptor method was originally designed as a preceptor-centered approach to help new medical preceptors teach learners, such as medical students, in a medical practice.2 However, this approach has also been labeled as both a student-oriented and patient-centered method.6 The one-minute preceptor approach consists of five tasks (termed “microskills”) that the preceptor and the learner perform when discussing a clinical case. The five tasks are as follows:
Neher and Stevens7 suggest that the one-minute preceptor method needs to be viewed as a flexible framework for communication and that once the preceptor is familiar with the tasks, their order can be modified or particular tasks can be selected from the list as the situation warrants. The method sometimes includes a final, sixth task, Conclusion.8 In this step, the preceptor ends the communication exchange by explaining the next step and the student’s role in this next step.
The School of Dentistry at Oregon Health & Science University (OHSU) has initiated a project to enhance the interactions between dental preceptors and students in the dental clinic, where preceptors reinforce the use of scientific evidence and critical thinking in preceptor-student discussions. This project is a result of a National Institutes of Health, National Institute of Dental and Craniofacial Research R25 grant. The project, named iCARE, is modeled after the one-minute preceptor approach as originally presented by Neher et al.2 iCARE is similar to the one-minute preceptor approach in that it consists of an ordered series of tasks, takes about five to ten minutes to follow, and facilitates an efficient exchange between the dental preceptor and the student in front of the patient. iCARE enhances the one-minute preceptor approach originally presented by Neher et al.2 in that it is deliberately both preceptor- and student-oriented, reinforces principles of critical thinking, and places more emphasis on evidence-based decision making.
Table 1 lists the action verbs that iCARE represents for the preceptor (left-hand column) and the student (right-hand column). The tasks are designed to guide them both in a positive conversation, so that the student ultimately learns to assess personal dental skills and his or her knowledge base, develops problem-solving skills, and becomes less dependent on the preceptor for step-by-step instructions. The lower-case “i” in iCARE represents the subordination of the preceptor’s and student’s egos to the clinic task at hand: to exchange information in a professional, tactful manner in order to provide the best available patient care. The upper-case “CARE” in iCARE represents the balance of teaching, training, and patient care that are embodied in the clinic setting.
From the preceptor’s perspective, the iCARE approach involves the following five tasks:
Thus, from following iCARE, the dental preceptor can help the student reflect on his or her own knowledge base and understanding of the scientific literature, use scientific reasoning to problem-solve the patient’s dental condition, and assess the adequacy of the student’s diagnosis and treatment plan.
From the student’s perspective, iCARE can be used to help formulate a description of the patient’s condition and to lead the student through an assessment of his or her own problem-solving abilities. The following five tasks are involved:
By following the framework described here, the student and the dental preceptor are given a strategy for interacting with each other and with the patient. The preceptor’s focus is on eliciting information from the student to enable the preceptor to assess the student’s ability to problem-solve using the student’s knowledge base and to collaboratively design care based on scientific evidence. The student’s focus is on applying evidence-based principles and demonstrating a comprehensive knowledge of the patient’s condition that has been critically analyzed. Through this framework, the student learns that all oral health care needs to be supported by evidence-based principles. The student also learns that, as a developing professional, he or she needs to educate and advise patients from a foundation of best available scientific evidence. Within this framework, the patient benefits from a collaborative approach to problem-solving, knowing that the student and preceptor were comprehensive in their exploration of solutions in which scientific evidence was integrated with clinical experience. The patient is then able to make the most informed decision for care.
The one-minute preceptor approach facilitates communication between the preceptor and student, maximizes the available teaching time in the clinic, and helps the student approach patient care in a positive, problem-solving manner in light of published scientific principles and data. When initially used, there may be a degree of discomfort with the approach, but as Neher and Stevens7 point out, taking time to reflect briefly on the set of tasks at the end of each teaching day can increase the preceptor’s comfort level with the approach.
Since the introduction of the Neher and Stevens7 one-minute preceptor approach to teaching in a clinic setting, the approach has been found to be easy to learn and effective in helping preceptors improve their teaching.8,9 In one study, second- and third-year internal medicine residents were given a one-hour training session on the one-minute preceptor, including role-playing, with residents in the role of the preceptor.10 Medical students reported that the residents who received training showed statistically significant improvements in all teaching domains except “teaching general rules.” The greatest improvement was noted in items that addressed “asking for a commitment,” “providing feedback,” and “motivating me to do outside reading.” Residents in the intervention group self-reported significant improvement in all teaching behaviors (P<.05), and 87 percent of the residents rated the approach as “useful or very useful.” In another study,9 teaching behaviors of board-certified internist faculty preceptors for third-year medical students were assessed after a faculty development workshop based on the one-minute preceptor model. The amount and quality of feedback were measured. After the workshops, instructors reported that they were better at letting the students reach their own conclusions (P=0.001).
Aagaard et al.11 found that the traditional model focuses on “missed areas” and provides relatively little instruction. Aagaard et al. additionally found that preceptors using the one-minute preceptor approach were equally or better able to diagnose the patient’s condition correctly, in comparison to those using a traditional approach, and the one-minute preceptors were better able to assess students’ abilities and knowledge. The preceptors rated the one-minute preceptor approach more efficient and more effective. In comparing the one-minute preceptor approach to the more traditional model, Irby12 found that preceptors using the traditional approach were more likely to teach generic skills, such as history taking and presentation skills, while preceptors using the one-minute preceptor approach were more likely to teach about the patient’s specific illness in terms of diagnostic tests and the natural progression of disease.
As noted by Pugh,4 what marks clinical education as different from other branches of education is the role of the patient. The patient is the audience to the exchange between clinic instructor and student. Engrossed in their exchange of information, the preceptor or student (or both) sometime forgets that the patient is present and all too often forgets that their exchange is an opportune moment for teaching and learning. Chair-side, both the preceptor and the student need to exchange information efficiently. The preceptor quickly analyzes the student’s skills and knowledge base, assesses the student’s diagnosis and treatment plan, and teaches about dental principles and their application to patient needs. At the same time, the student assesses his or her own skills and knowledge base, assesses familiarity with the scientific literature, assesses the tentative diagnosis and treatment, and evaluates how well dental knowledge and skills were applied to the current patient’s case. The preceptor and student in the dental clinic need to be prepared for their exchange and to be appropriately responsive to each other, not only to achieve an effective exchange in the dental clinic, but also to prepare the student in the compassionate and appropriate exchange of information with the patient in the dental office after graduation.
After graduation, the new dentist practices without the daily guidance of clinic preceptors, so it is important for iCARE, as an evidence-based diagnosis and treatment framework, to be internalized through repetition in school and in the dental clinic, ultimately resulting in the framework becoming the basis for critical thinking in practice. iCARE merges evidence-based dentistry principles with effective professional communication skills. iCARE can help dental preceptors and students provide the best available care for patients while students enhance not only their knowledge of oral health principles but also their abilities to analyze and apply evidence from scientific studies to patient cases in the formulation of diagnoses and treatment plans.
This research was supported in part by NIH NIDCR Grant R25 DE18206.
This project was supported in part by NIH NIDCR Grant R25 DE18206. The author thanks Dr. Sandra Oster for her contributions in editing this manuscript. The author also thanks Ms. Jennifer Priest Mitchell, Ms. Linda Lin, and Dr. Niki Steckler for their contributions in developing the concept of iCARE.