Embed Size (px)
Citation preview
Medical Teacher, Vol. 7, No. 3/4, I985 289
The Way We Teach Psychology to Dental Students
GERRY KENT, Lecturer in Behavioural Sciences, University of Sheffild
SUMMARY There is increasing interest in the teaching of psychology to undergraduate dental students. This paper describes a course given at ShefjWd University, where the topics covered have been chosen after consultation with practising dentists. Those areas which dentists find most troublesome include patients’ anxiety, pain, and aspects of the dentist-patient relationship. The course aims to provide undergraduates with some back- ground in the methods of the social sciences as well as to give practical information about psychological therapies.
Introduction
In the mid-1960’~~ only a few medical schools in Britain included psychology in their curricula, Sheffield being one of the first to employ a clinical psychologist for that purpose in 1960. The 1968 Todd report [ 11 recommended a substantial increase in behavioural sciences teaching in medical schools with the result that virtually all medical undergraduates in Britain now receive some psychology and medical sociology. The size of the commitment and its importance relative to the traditional pre-clinical subjects varies considerably, but the teaching of psychological and sociological ideas is now firmly established. By contrast, only a few of the 16 dental schools in Britain and Northern Ireland have a formal behavioural sciences input, a situation rather similar to that in the medical schools in the middo’s. However, there are indications that this is about to change. The General Dental Council’s [2J recommendation that the course should “provide students with some knowledge of the psychological aspects of patient care, with special reference to the relationship between dentist and patient ...” (page 5 ) and the Nuffield Foundation’s [3] suggestion that training “should pay particular attention to the skills of communi- cation and to interpersonal relationships” (page 45) may have a similar effect to the Todd report, leading to a significant increase in behavioural sciences teaching in dental schools.
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
290 Gerry Kent
Partly as a result of these recommendations and partly because of an internal curriculum review, the author, a psychologist, was asked to provide a short lecture course in psychology to pre-clinical dental students beginning in the 1980-1 981 session. This was designed to complement other ‘social type’ teaching which presently includes lectures on epidemiology and psychiatry. This paper argues the case for the inclusion of psychology in dental curricula, provides a description of the aims and content of the course and makes some personal observations on teaching the subject to dental students.
The Case for Psychology
The dentist’s problems
The argument for the inclusion of psychology in dental curricula bears on the needs of both patients and practitioners. Dentists claim that relationships with patients constitute the most important stresses in general practice. For example, when experienced dentists in one study were asked to indicate the degree of stress involved in various aspects of their practice, ‘Coping with difficult patients’ was given the highest ranking. When these problems are analysed further, aspects of the dentist- patient relationship (where patients seem rude, inconsiderate or, more simply, ‘a pain in the neck’) and patient anxiety are particularly troublesome. Patients’ anxiety affects the dentist in several ways. Not only do tense and agitated patients make the technical aspects of treatment difficult, but they arouse uncomfortable feelings in the dentists themselves. There are also indications that anxiety can disrupt the orderly progress of appointments. In one study patients were posted a questionnaire designed to measure their anxiety several days before they were due to have their scheduled appointment: only 8% of those who reported low anxiety either cancelled their appointment or failed to keep it while 24% of the highly anxious patients did not attend. Some further problems cited by dentists are listed in rank order in Table I. Virtually all of these have received attention from psychologists, some more directly than others. The bulk of research in applying psychology to dentistry has concerned anxiety, pain and prevention, although there is an expanding interest in the dentist-patient relationship.
TABLE I. Problems cited as particularly troublesome by practis- ing dentists in order of frequency (reproduced from Kent, G.
(1983) British Dental Journal, 154, p. 107)
Rank Order
Dentist-patient relationship Patient anxiety Prevention Dentists’ personal feelings Patients’ unrealistic expectations Practice management Children’s behaviour problems Conflicts with parents over children’s care Patients’ pain
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
Teaching Psychology to Dental Students 291
The patient’s problems
If patients cause their dentists to have problems, so too can the dentist contribute to patients’ difficulties. Anxiety, for instance, is not always associated with a fear of pain per se. When asked about the reasons for their anxiety, patients often report that it is the dentist’s behaviour and personality which concerns them most. Many anxious patients cannot remember any particular traumatic experiences in the dental chair, while non-anxious patients sometimes do have such memories. There are indications that, for the latter group, a ‘warm’ and ‘caring’ dentist alleviated any long-term effects of dental pain. Another important area is dissatisfaction with care, which has been related to utilisation patterns and compliance. It seems that dissatisfaction is just as likely to be attributed to a lack of the dentist’s social skills as to his or her technical ones. A third way in which the dentist may quite unwittingly contribute to patients’ difficulty is in the siting of the surgery. Access to a second or third floor office may pose no problem to the able-bodied, but for the elderly and handicapped people a flight of stairs could be enough to discourage regular care.
Providing assistance
Simply calling attention to such difficulties as siting will be useful in many instances. But psychologists can do more than help identify problems-they can also offer much practical assistance. Anxiety about dental care responds well to several techniques, while behavioural interventions can be used to increase preventive care and reduce such deleterious oral habits as bruxism and thumbsucking. Modern theories of pain emphasise the important role of emotional and cognitive factors so it, too, is open to psychological intervention. With some background in psychology, many of the techniques involved in reducing anxiety and pain and encouraging prevention can be used by dentists themselves, without recourse to clinical psycho- logists.
Aims of the Course
The most important decision about the course concerned whether psychology would be presented as an academic or as an applied discipline: whether the emphasis would be placed on theoretical aspects of psychology or on the ways that psychology can contribute to patient management. Three factors influenced the decision. The first was the fact that only 10 hours were available. Obviously, this did not provide time to describe complex theoretical positions in any depth. The second factor was the views of the students themselves. Informal discussions with students (and general dental practitioners) indicated that their main concerns were with the practical difficulties of treating patients. They had little interest in, for example, methods of constructing and validating personality questionnaires: rather, they wanted to hear about how a questionnaire could be used in practice, what it could tell them and if it could help them manage patients. The third factor was a personal concern for the welfare of patients. Since psychology has been applied successfully to many of the problems encountered in dentistry, there was some responsibility to transmit this information to the students. Accordingly, the 10 hours were largely devoted to psychology as it is relevant to dental care, with theoretical concerns being discussed when they were relevant to practical considerations.
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
292 Gerry Kent
Within this general stance, there were three specific aims: (i) To increase understanding of several problems encountered by general dental
practitioners. These include patients’ lack of preventive care, reasons for irregular attendance and causes of anxiety and pain.
(ii) To increase awareness of the range of psychological therapies available and to provide evidence of their effectiveness.
(iii) To provide some background in methodology in the social sciences.
The Content of the Course
The titles of the ten lectures are outlined in Table 11. Each lecture was designed to meet at least two of the above aims. For example, a piece of research on anxiety might be chosen not only for its substantive contribution but also because it demonstrates a methodological point or provides an example of a particular measur- ing instrument.
TABLE 11. The lecture timetable
Lecture Content
1
2 3 4 5 6 7 8
9 & 10
Introduction. The relevance of psychology to
Anxiety. The nature and causes of anxiety Anxiety. The alleviation of anxiety Pain. The nature and measurement of pain Pain. The alleviation of pain Prevention. The educational approach Prevention. The behavioural approach The dentist-patient relationship Special groups. Orthodontics, TM J pain-dysfunction
dental care
syndrome, handicapped and elderly people
1. Introduction
The main purpose of this lecture is to capture the students’ attention. A serious problem faced by psychologists teaching clinical students (medical as well as dental) is credibility. With some justification, students often claim that psychologists are too idealistic and ‘really don’t know what it’s like’ to be a doctor or dentist. This difficulty can be turned to the lecturer’s advantage if it is acknowledged and the claim is made that the content of the course has been influenced by the opinions of qualified dentists. I do this by describing studies which report the kinds of problems dentists encounter with patients, e.g. [4] , and then following these results fairly closely. This is supplemented by research on patients’ points of view: how they come to choose a particular dentist [ 5 ] and the kinds of experience which would cause them to lose confidence [ 6 ] . This introduction also makes the practical slant of the course explicit.
The rest of this lecture is devoted to a central problem in psychology-the prediction of behaviour. The example used is regularity of attendance at the dentist’s, where the discrepancy between attitudes and behaviour is large. That almost all the people in the general population agree that it is important to visit the dentist regularly yet less than half do so is one illustration that the relationship
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
Teaching Psychology to Dental Students 293
between what people believe and what they do is more complex than common sense might suggest. What kinds of variables might be important here and how could we measure them? Students are encouraged to participate by giving their own explana- tions for the discrepancy. The most common suggestions include fear of pain, dislike of dentists and cost. Research bearing on these ideas is presented where possible. The aim of this exercise is to involve the students in the teaching and to make it clear that psychology can answer many of the questions they ask themselves.
2 & 3. Anxiety
These two lectures are on a topic familiar to most psychologists. The first optlines research on the measurement of anxiety and theories about its aetiology. The second lecture discusses the various psychological therapies which have been found to be successful in the alleviation of dental anxiety. A segment of a tape recording of progressive relaxation instructions is played.
4 & 5 . Pain
Another traditional topic for psychologists. The first lecture describes modern theories of pain-with emphasis on Gate Theory and the association between anxiety and pain-and the difficulties of measuring pain. The second lecture describes various psychological techniques which have been used to alleviate pain in dental patients.
6 & 7. Prevention
Knowledge about the technical aspects of preventive care that students acquire during their training will be of use only to those patients who are willing to accept treatment and advice. Since these form a minority of the general population, an understanding of the psychological and social aspects of preventive care is crucial. These two lectures consider educational and behavioural approaches to the problem. The first, on education, covers research on communicator credibility and the Health Belief Model. The Flesch Formula [7] , which measures the ‘readability’ of printed information is discussed. As a preparation for this, the students are asked at the end of lecture 5 to write a short (200 word) pamphlet which they might provide for their future patients explaining the need for preventive care. This pamphlet was to be written during the intervening week and brought to lecture 6. After the Flesch Formula is discussed, the students are asked to score their pamphlets and calculate the proportion of the general population who could be expected to understand it. The idea that education might be a necessary but not a sufficient condition for a change in behaviour is introduced by examining the effectiveness of some educa- tional programmes.
The second lecture on prevention outlines the behavioural approach, including both operant and cognitive-behavioural methods. At the end of the lecture a handout based on Weinstein & Getz’s [8] programme is given to the students. The main headings are shown in Table 111, which indicates the type of approach taken here. In addition, an example of a chart which could be used to monitor how often patients brush or consume sugar is provided.
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
294 Gerry Kent
TABLE 111. The main headings for the handout on designing a preventive programme.
1. 2. 3. 4. Changing the behaviour (shaping) 5 . Reinforcement 6. Failures in preventive programmes
A clear and precise definition of the problem Monitoring the frequency of the problem behaviour Specifying the aims of the intervention
8. The dentist-patient relationship
The main aim of this lecture is to emphasise the point that the dentist’s social behaviour has a significant effect on patients’ willingness to take up and be satisfied with their care. The results of the three studies mentioned in the introductory lecture [4, 5, 61 are recalled here and others which were designed to gauge patients’ perceptions of their dentists are added.
Unfortunately, there is no time available in this course to provide the one-to-one training in interpersonal skills which seems so valuable 191. Instead, the lecture is supplemented by a description of the training programme outline by Jackson [lo]. He argues that the establishment of rapport between dentist and patient depends on the ability of the dentist both to attend to the patient’s feelings accurately and to respond appropriately. He provides some examples of how the dentist could ‘look behind’ a patient’s comments, translating them into their emotional meaning:
“I liked.. . I went to him for 30 years, you know” could be translated into:
“I’m not sure that I trust you” and to ‘look behind’ their own replies, as in the exchange:
Child patient: “I hate dentists; I don’t want to be here”.
Dentist: “Come now”. “Even your little brother Joe didn’t mind “I want to go home”.
his check-up”. “Be a good boy and open your mouth”. which could be translated into:
Child patient: “I am afraid”. Dentist: “Because you are afraid I think that you are both childish
The students find these notions (borrowed from ideas in verbal psychotherapy) interesting and useful. The lecture is completed by the suggestion that they spend some time during the next week translating their own and friends’ comments into emotional content.
and bad”.
9 & 10. Special groups
These two lectures provide an opportunity to discuss some areas of psychology not covered previously. Research on orthodontics, for example, includes some interesting work on social and self-perception, while some of that on the TM J pain-dysfunction syndrome opens up the idea of illness behaviour. Mention is made of the problems that physically handicapped people have in gaining access to dental care (which involves the design and siting of dental surgeries) and, as the proportion of people
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
Teaching Psychology to Dental Students 295
in the general population who are elderly increases, it is important to make some mention of the particular difficulties they face.
Some Personal Observations Some further aspects of my own experience may be useful for a teacher planning this type of course. At the risk of making an unfounded generalisation, dental students do appear to be much more practically minded than either psychology or medical undergraduates. Theoretical discussions needed to be justified by their practical implications, rather than because they may be interesting (to a psychologist) in their own right. It was only when theoretical psychology was dressed in practical clothing that it was acceptable to the students.
Another point concerns access to published material. When I began to research material for the course I anticipated that it would be necessary to ‘borrow’ studies from the medical literature. With few exceptions, this proved not to be the case: there is a wealth of material available. The most useful source is the Index to Dental Literature, while Psychological Abstracts has a section on ‘Dentistry’. The situation is further improved by the recent publication of some textbooks [ 1 I, 121 .
A third point concerns the timing of the teaching. The general Dental Council appears to recommend that psychology be taught early in the course and this option was followed at Sheffield initially. However, it became clear that this was unsatisfac- tory. With minimal patient contact, students found it difficult to relate what they were learning in psychology to their future practice. Accordingly, and partly at the students’ request, psychology is being shifted from the pre-clinical to the clinical years. Currently, the Curriculum Committee is considering the possibility of dispers- ing the psychology teaching throughout the later stages of the course; rather than giving the lectures in a single block, those on prevention, for example, could be given when the students are learning about the technical aspects of preventive dentistry.
Correspondence: Dr G. Kent, University Department of Psychiatry, Floor ‘O’, Royal Hallamshire Hospital, Glossop Road, Sheffield S 10 2 JF, U.K.
REFERENCES [ 1 I ROYAL COMMISSION ON MEDICAL EDUCATION (1968) Report of the Royal Commission on Medical
[2] GENERAL DENTAL COUNCIL (1980) Recommendations concerning the dental curriculum (London,
[3] NUFFIELD FOUNI)ATION (1980) An inquiry into Dental Education: A report to the Nuffield Foundation
[4] KENT, G.G. (1983) Psychology in the dental curriculum, British DentalJournal, 154, pp. 106-109. [ 51 BULMAN, J.S., RICHARDS, N.D., SLACK, G.C. & WILLCOCKS, A.J. (1968) Demand and Need for Dental
[6] KREISBERG, L. & TREIMAN, B.R. (1962) Dentists and the practice of dentistry as viewed by the
[7] FLESCH, R.P. (1951) How to Test Readability (New York, Harper & Row). [8] WEINSTEIN, P. & GETZ, T. (1978) Changing Human Behaviour (St Louis, C.V. Mosby). [9] FURNHAM, A. (1983) Social skills and dentistry, British Dental Journal, 154, pp. 404-408.
Education (London, HMSO).
General Dental Council).
(London, Nuffield Foundation).
Care (London, Oxford University Press).
public, Journal of the American Dental Association, 64, pp. 806-821.
[ lo ] JACKSON, E. (1975) Establishing rapport. 1. Verbal interaction, Journal of Oral Medicine, 30,
[ 1 l ] INGERSOLL, B.D. (1982) Behavioural Aspects in Dentistry (New York, Appleton-Century Crofts). [ 121 KENT, G.G. (1984) The Psychology of Dental Care (Bristol, John Wright).
pp.105-110.
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 10
/26/
14Fo
r pe
rson
al u
se o
nly.
