Why a new course?

The key comment in The first five years is the integration of teaching of medicine, surgery and allied subjects. We would totally endorse this view as a lack of integration was a major shortfall when these subjects were taught separately. Often in the BDS curriculum, pathology and microbiology were taught first (frequently in Year 3) and medicine and surgery in Year 4. Pharmacology and therapeutics were taught either in Year 3 or 4. Thus the students would know about the pathology of atheroma formation but have little knowledge of the clinical outcomes. Likewise, the students would be taught about the microbiology of infective endocarditis but have sparse insight into the clinical features of this disease. Other examples would occur in pharmacology and one of the most obvious examples would be students receiving a lecture on anti-hypertensives with little or no knowledge of hypertension and its sequelae. As courses in pathology, microbiology, medicine, surgery and pharmacology were so embedded in the curriculum and followed rigorous time frames, a major change in direction was required.

There was also considerable overlap and repetition in the old style courses. Whilst some repetition was desirable, there was duplication, especially between medicine, surgery and general pathology.

A further problem often reported by dental schools was the quality of teaching, especially in the areas of medicine and surgery. Previously, it was the remit of the professors of these disciplines to provide the respective course. The job was frequently delegated which gave rise to problems of continuity. Often NHS consultants were asked to deliver parts of the course and this clashed with their hospital commitments (which took priority). As a consequence, teaching was further delegated, often at short notice, to junior staff. The outcomes were unsatisfactory.

The problems were further compounded by a lack of knowledge of what to teach the dental students or, more precisely, what depth of knowledge was required. This led to considerable confusion for all parties. Often such courses were poorly received and this was reflected in student attendance patterns.

Courses in both medicine and surgery also provided opportunities for patient contact in a hospital setting. These invariably took the form of ward rounds, where again, teaching was very variable. The emphasis in The first five years is on examination of the clothed patient, and whilst ward rounds may have had some value, it was difficult to see the relevance to the dental setting. Ward rounds were not always delivered by a consultant and the teaching experience was related to patient availability and willingness to participate. With the move to more day case procedures, the supply of 'useful' patients across the board has reduced. This background again provided an impetus for change.

The teaching of pharmacology and therapeutics was prone to similar problems, although to a lesser extent. Some schools had dedicated teachers to cover this topic, whilst others relied upon support from the pharmacology department. For some pharmacological topics, especially the ones relevant to dentistry – for example local anaesthesia, antibiotics, sedation agents etc – the staff within the school often provided the lecture programme. Courses in general pathology were usually organised by oral pathologists and some schools were fortunate to have dedicated teachers in microbiology.

It is against this somewhat chequered background that a change was required. The focus needs to be on the impact on patient management and relevance to dentistry. This has formed the basis of our course in Newcastle.

The human diseases course

The current course in Newcastle extends over two years starting in the third year of the BDS degree. The course is organised on a body systems basis. At the conclusion of each system is a lecture or clinical demonstration on the dental relevance of the preceding subject matter.

An example of the integrated approach to teaching is given in Figures 1 and 2 which shows the cardiovascular module of the Newcastle course and its objectives. From this it can be seen that the disciplines which make up human diseases are included but are not rigidly separated from one another. The dental relevance is given at every stage but also summarised in the final lecture or clinical demonstration. This may involve a degree of repetition but is done in a conscious way to facilitate learning rather than as a result of an uncoordinated approach.

Figure 1
figure 1

The integrated approach to the teaching of cardiovascular disease in the human diseases curriculum

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Figure 2
figure 2

What the student should know at the end of the module

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A proportion of the lectures are still delivered by physicians and surgeons, but the majority are given by staff from within the school. This has significantly reduced the incidence of lecturer non-attendance which was a particular problem with the old course. There is also the added advantage that the dental relevance of medical conditions can be given at every stage.

Towards the end of the fourth year course, students are taught in small groups. The main aim of the initial tutorials is to ensure that the students are proficient in eliciting the vital signs and other basic clinical signs. Further tutorials are provided which enable the students to take medical histories in detail from patients or appropriately briefed actors. Attendance at these sessions is compulsory.

Assessment

Professional examinations in human diseases occur at the end of the third and fourth years. It is felt necessary to include two examinations partly due to the sheer volume of subject material, but also the examination in the fourth year serves to consolidate some of the information which has been gained during the third year. The exams are assessed completely separately and performance in one examination is not taken in to account with regard to the other. In the third year, students are assessed by means of an Extended Matching Item (EMI) question paper and a structured short answer paper. Vivas have been conducted for borderline and meritorious candidates.

We have felt that the use of vivas in this examination was useful, but are aware of the fact that viva examinations are somewhat controversial. In this examination vivas were only used to help candidates and this was made clear to the students. No student's mark was lowered as a result of a viva. In an attempt to be as objective as possible the vivas were structured to ensure a consistent approach. From 2008, in common with many other universities, the use of selective vivas will be discontinued.

The fourth year assessment includes a summative case report which assesses the students' ability to retrieve and critically evaluate current concepts in a particular area of general medicine or surgery relevant to dental practice. The examination itself comprises of a further EMI and structured short answer paper together with an Objective Structured Clinical Examination (OSCE). Vivas have been conducted as for the third year. The small group teaching at the end of the fourth year is assessed on a formative basis.

The OSCE has an important role in the assessment of a student who is coming to the end of the human diseases course. It provides an opportunity to assess the students' interaction with simulated patients and their ability to elicit a relevant history as well as the performance of some practical procedures. Examples of the latter include cannulation and cardiopulmonary resuscitation.

In Newcastle, we run three simultaneous OSCE circuits which may accommodate up to 20 students per circuit. This has led to the use of simulated patients (actors) rather than 'real' patients as the circuits must be identical. This would be very difficult to achieve with patients. The use of appropriately briefed actors enables a degree of reproducibility to be achieved.

Where a patient is essential the use of video recording has been employed. This is particularly useful when the history forms the basis of the subject to be examined. On our course we have employed this technique for testing students on the assessment of psychiatric patients.

Student feedback

Feedback for the old medicine and surgery course was gained via the staff/student committee. The feedback covered several domains and was universally less than satisfactory. Particular problems were a lack of integration, a lack of lecturer knowledge of what was required and lecturer non-attendance. Feedback for the human diseases courses gained in the same way and has been uniformly positive. Figure 3 includes a synopsis of the feedback scores for the human diseases course. The year providing the feedback comprised 64 students but it can be seen that the feedback was obtained from 53. Whilst it is accepted that the feedback from the 11 students who did not reply would be very valuable, even allowing for this factor the feedback is positive.

Figure 3
figure 3

Summary data of the BDS Staff/Student Committee 2005

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The role of the human diseases course coordinator

The first five years recommended that each dental school should have a nominated representative whose remit was to coordinate the teaching of human diseases to undergraduate dental students.

Most of the course coordinators in the dental schools are drawn from the speciality of oral medicine with some schools using maxillofacial surgeons. The majority of these clinicians are qualified in both medicine and dentistry and therefore have the advantage of an education in, and often experience of, the conditions on which they are lecturing. We believe that this is beneficial for the students. It is essential for the course coordinator to have full support from his/her colleagues and those that contribute to other parts of the programme. The course coordinator ensures content, quality and structure.

Patient contact

We have commented that the old courses in medicine and surgery provided opportunities for patient contact. The guidelines of The first five years emphasised that students must be able to observe and interpret physical signs in the clothed patient. Whilst ward rounds on the 'old' course may have provided some insight into the workings of a hospital it is more relevant to dentistry for students to have awareness of the workings of an oral and maxillofacial surgery unit and the accident and emergency department. When qualified, dental practitioners are likely to refer patients to oral and maxillofacial surgeons and referrals may be treated as in-patients. Likewise, unfortunate circumstances may occur in dental practice which would require referral to the accident and emergency department. Experience of these aspects of hospital practice is therefore beneficial.

To meet the challenges of observation in the clothed patient, we provide a series of patient contact seminars where a range of medical conditions are discussed and their relevance to dentistry emphasised. This involves a cohort of real patients. Obvious examples include diabetics, solid organ transplant patients, asthmatics, patients with valvular heart disease and other cardiovascular disorders. The patient is the focus of the seminar. Students take medical and drug histories and then have an opportunity to discuss the possible impact of their medical condition on the delivery of dental care.

The seminars are led by members of the teaching team and groups of students rotate between cases. A large pool of patients is utilised for this exercise. Cases which have a significant dental complication such as drug-induced gingival overgrowth or diabetes exacerbated periodontal disease do help to enhance the dental relevance of this exercise.

Relevance of the human diseases course to dental practitioners

We have stressed throughout this article that the new course in human diseases should have significant relevance and implications for dentistry and the delivery of dental care. The educational experience should then be taken forward into the dental practice setting and help facilitate the management of the medically compromised patient in the primary care setting. For the most part, dentists need to be reassured on the management of the patient. This involves knowledge of drug interactions, preventing or managing medical emergencies and medically compromised patients. The dentist needs to recognise whether any oral changes are drug-induced or related to the patient's underlying medical condition.

Many medically compromised patients can be, and are, treated in primary care. New information on the management of patients on oral anticoagulants,2 long-term corticosteroids3 and the need for chemoprophylaxis4 has facilitated this. It is important that management is underpinned by a sound theoretical and practical knowledge.

Human diseases and the Bologna Process

The Bologna Process is an intergovernmental initiative which aims to create a European Higher Education Area (EHEA) by 2010 and to promote worldwide the European system of higher education. It was launched in 1999 and now has 45 signatory countries.

The main objectives of the Bologna Process were to remove obstacles to student mobility in Europe, to enhance the attractiveness of higher education and to establish common structures. Medicine and dentistry are integral to this process.

Human diseases teaching (but not specifically designated as such) does form a significant separate area in discussion documents, but some of the competencies and skills that are highlighted in other domains are also crucial to successful education in the sphere of what we designate as human diseases. Obtaining and recording a comprehensive medical history and performing an appropriate physical examination are regarded as major competencies. Also included in 'major' competencies are infection control and familiarity with pathological features and the dental relevance of disorders of the major organ systems. Knowledge of oral manifestations of systemic disease and knowledge of disease processes are all highlighted. Infection, inflammation, disorders of the immune system, degeneration, neoplasia, metabolic disturbances and genetic disorders are also specifically designated as major competencies.

There are fundamental differences in some countries of Europe. For example, in Italy the initial qualification of a dentist is a medical degree which inevitably alters the way that teaching in a human diseases context will be delivered compared to a more conventional dental training.

Conclusion

The interaction between the increase in life expectancy and advances in medical science means that increasing numbers of medically compromised patients will be requiring dental care. Our course provides the necessary background information for undergraduates to recognise these problems and then to be able to manage them safely in the clinical environment.