- Email: [email protected]
Problems in Dental Practice: A Pilot Study for Continuing Education
P
f
)
ART1CLES
Problems in dental practice: a pilot study for continuing education D o n ald H. B lan d fo rd , M A J. K en Dane
Continuing education is moving away from the traditional subject-m atter orientation. This study assesses the potential fo r problem -oriented continuing dental education p rogram s to h elp practitioners solve the problem s they encounter in practice.
T
he continuing professional com petence of the dental practitioner and the means of assuring that competence have long been a focus of attention for dental professional organizations and state and federal agencies. Whereas a variety of specific mechanisms for as suring competence have been pro posed, both current methods and suggested alternatives incorporate continuing dental education (CDE) as a primary tool for maintaining compe tency. Local and national professional o r g a n iz a tio n s have e sta b lis h e d m inim um CDE requirements for their members; several state agencies have established m inim um requirements in CDE as a condition of relicensure. Some have recommended more rigor ous systems to assure competency, such as peer review through profes sional standards review organizations and prescribed retraining in areas of deficiency.1
Recently, attention has been turned toward the continuing education pro cess and particularly toward the rela t io n s h ip b e tw e e n e d u c a t io n a l methods and what an adult learns. Francis2 has called for a reorientation of continuing dental education toward a self-directed, problem-oriented ap proach. This approach, based on re search3and theories of adult learning,4 suggests that adults learn best when education is directly relevant to the problems that they are experiencing. The problem-oriented approach to education is offered as a contrast to the current approach of CDE, which is or ganized primarily around subject mat ter categories such as crown and bridge, endodontics, and practice ad ministration. The interest in problem-oriented continuing education transcends den tistry and is virtually a movement in the health professions. Practitioners in
m edicine,5 pharmacy,6 nursing,7,8, and the auxiliary health professions9 have all advocated a problem-oriented approach to continuing professional education. The implementation of at least some problem-oriented continuing educa tion, if only on a pilot basis, may be de sirable both because of its theoretical promise and because it may afford an opportunity to examine more directly the impact of CDE on professional competency. However, there are sev eral fu n d a m e n tal barriers to im plementation at the present time. First, the lack of systematic knowledge about the types of problems faced by dentists in practice makes it difficult to identify appropriate areas for course development. Second, there is little systematic knowledge about the cur rent problem-solving behavior by den tists in practice. Such knowledge is necessary for the developm ent of courses that will build on the profes sional competencies and the patterns of resource use already in place. The present study was designed to investigate the natural history of prob lem identification and problem solv ing in dentistry. The specific purposes of the study were to identify and analyze clinical and nonclinical prob lems commonly met by general dental practitioners during the lifetime of a dental practice and to identify and analyze the strategies and resources commonly used by dentists in resolv ing these problems. Information re sulting from the study should facilitate the development and implementation of problem-oriented approaches to CDE.
Study methods The study involved nearly 50 dentists and dental practice consultants, who were organized into a steering com m itte e charg e d w ith p r o v id in g methodologic and analytic assistance JADA, Vol. 103, December 1981 ■ 869
ART ICLES
throughout the study; two project con sultants, one expert in continuing den tal education, the other in adult educa tion, who provided technical advice and assistance throughout the study; and four task groups composed of full-time dental practitioners and den tal practice consultants, who provided specific information on clinical and nonclinical problems in dental prac tice and the strategies and resources used to resolve these problems.
Selection of participants The steering committee was composed of six professionals: four practicing dentists and two dental practice man agement consultants. The members were selected to assure a wide range of private practice experience and con sulting experience and a high level of conceptual ability. The four task groups were each composed of seven dental practition ers and two dental practice consul tants. The 36 task group members were selected from 125 nominations pro vided by dental professional organiza tions, dental schools, steering com mittee members, and other sources. Task group members were assigned to a particular group based on certain c h a ra c te ristic s . A m ong a ll task groups, efforts were made to vary the m embers’ characteristics, such as length of time in practice, geographic location, and type of consultant prac tice (for example, private consultant, university-based consultant, and man agement-firm based consultant). Thus, the task groups were intended to be a deliberate sample of dental practitioners and practice consultants from around the country. Both indi vid ually and collectively, the task groups brought together dental practi tioners and consultants whose experi ence covered a broad range of per sonal, professional, and practice characteristics.
Study design Workbooks and structured group meetings were used to collect data. The steering committee met twice dur ing the formative stages of the study and once after the task group meetings to assist in developing the materials and methodology for obtaining infor mation from task group members, de
870 ■ JADA, Vol 103, December 1981
veloping the process for obtaining task group nominations and selecting task group members, and advising on the analysis of data and presentation of re sults. A behavioral definition of dental practice problems was developed and adopted. This definition relates the perception of a problem to its resolu tion: A problem in dental practice is an event, or a series of events, per ceived by a dentist as having an adverse impact on the quality of care provided to patients or on the efficient operation of the dental practice. Either the seriousness or the recurring nature of the event suggests the need to alter the be haviors or circumstances that produce the events. In light of this definition, the failure of a single patient to arrive for a sched uled appointment probably would not be viewed as a problem; however, the recurring failure of patients to meet appointm ents probably w ould be. Similarly, paperwork may be a general problem, but a more specifically iden tifiable problem may be the appropri ate completion of insurance forms. Additionally, some individual events may be so important that they are im mediately perceived as problems. For instance, the failure of appropriate staff to respond to an in-office emer gency may be so important as to re quire immediate resolution. A classification scheme for prob lems was developed by the steering committee for use in the design of task group workbooks. The classification scheme, shown in Figure 1, enables the identification of indiyidual prob lems in three major areas and 13 prob lem categories, and may be the first scheme that attempts to classify the full range and complexity of dental practice activities. One workbook fo cused on the identification and de scription of problems; the other, on the description of solution strategies and resources for problem solving. The questions in the workbooks were based on the problem classification scheme and included examples of general problems associated with each problem area. Task group members completed the workbooks by identify ing their own problems and answering a series of questions about each prob lem (Fig 2).
Four task group meetings were held during May and June 1980. Two task groups focused primarily on problem identification and description; two task groups focused on solution strate gies. A ll four meetings were con ducted using a similar format. A pre meeting workbook was mailed to task group members approximately two weeks before each meeting. Members completed and returned the work books, which were then transcribed and organized to serve as points of de parture for discussion at the meetings. The meetings were structured to en courage participation and contribu tions by all task group members.
Results Types of problems identified Thirty-three task group members completed and returned workbooks. A total of 324 individual problems were described, and details of either prob lem identification or the strategies and resources used in problem solving were provided. Table 1 shows the distribution of problems among the three problem areas. About a third of the problems involved the human relations aspect of dental practice, problems involving patients, staff, external consultants, and the practitioner’s own psyche. More than 40% of problems described concerned management of the ad ministrative and operational aspects of practice. These are primarily systems management problems. Only a fourth of the problems described concerned technical I clinical difficulties. In this study, the bulk of problems described by task group members were practice administration problems (75%), rather than clinical problems (25%).
Problem-solving resources Table 2 summarizes the number of times that specific problem-solving re sources were mentioned. The resource most frequently mentioned was peer co n sultation . In d e p e n d e n t study (journal reading) and use of consul tants or other professional support (practice management consultants, lawyers, and accountants) received the same number of mentions and were the next most frequently noted re sources. CDE, including both schoolbased continuing education and den-
A R T IC L E S
Taxonomy of problems in dental practice MANAGEMENT Problems that arise as a result of, or incidental to, human interactions, including interactions with staff, patients, or other persons who come in contact with the practice.
Problem area categories Patient m anagem ent problems result from in teractions of patients with the practitioner or staff, including problems of patient motivation and compliance. P ersonnel m anagem ent problems result from interactions of practitioner with his or her staff, including all phases of hiring, retention, dis missal, and motivation of employees. Office m anagem ent problems result from lack of coordination between practitioner, staff, and other support, including problems of patient scheduling and the flow os staff, practitioner, and patients. Personal m anagem ent problems arise from the practitioner’s attitudes, values, and capabilities with respect to the professional role.
ADMINISTRATIVE/OPERATIONAL Problems that relate to office coordination and management, excluding human interactions, including problems of paperwork, overall effi ciency, design of office, and business and prac tice management concerns.
Problem area categories Office m anagem ent problems result from deci sions about the conduct and procedures used in the management of the practice, considerations of the practice styel, and marketing procedures. Environm ental m anagem ent problems arise
from design of office and facility spaces, and the work environment and its hazards. Clinical efficiency problems result from the in effective use of equipment, time, dental prod ucts, or coordination with professional support. Business m anagem ent problems involve cash flow, record keeping, and accounting, and deci sions about fees, billing, recall systems, insur ance coverages, credit, collection, and office policies. Clinical process m anagem ent problems result from practice style, practitioner needs, or in adequate clinical skills.
TECHNICAL/CLINICAL Problems that result from treatment of the pa tient, including all phases of patient treatment from the patient’s history to follow-up treatment procedures.
Problem area categories History and examination problems result from inadequate records of information relevant to the patient. Inadequate record keeping can lead to diagnosis, treatment, and follow-up prob lems. Diagnosis problems result from the process of analyzing patient problems and providing a diagnosis. Treatment problems result from decisions con cerning treatment procedures and possible problems during treatment. Follow-up problems result from either postop erative complications or decisions by the practi tioner concerning follow-up treatment.
Fig 1
tal society meetings, was the fourth most frequently mentioned problem solving resource. Review of the indi vidual problem descriptions indicates that several resources were used in solving a majority of the problems. The use of experts', peers, and inde pendent study together received a clear majority of mentions as resources used to solve problems in dental prac tice. Interestingly, CDE and dental so
ciety meetings accounted for only 15% of the mentions as resources for solv ing practice problems. These results clearly suggest that most problems in dental practice are solved outside the formal CDE framework.
Problem identification All problems identified were reviewed and grouped on the basis of similarity,
resulting in the specification of 86 separate problems for analysis pur poses: 31 problems in the area of man agement, 27 in the administrative I op erational area, and 28 in the technical I clinical area. For each problem, sum maries were prepared, w hich inte grated all available information on problem identification, point of occur rence in practice, resources used to re solve the problem, strategies used in
Blandford-Dane : PROBLEMS IN DENTAL PRACTICE STUDY FOR CONTINUING EDUCATION ■ 871
Types o f questions in w orkbooks Problem definition workbooks
Solution strategies workbooks ■ Describe the problem. ■ What resources did you use to re solve the problem? ■ What strategy (pattern of use of re sources) did you use to resolve the problem? ■ How much planning was involved in solving the problem? ■ What was the outcome of the prob lem? ■ Describe your use of the following resources in resolving the problem: continuing education courses, dental practice consultants, independent study.
■ Describe the problem. ■ At what point in practice did the problem first occur? ■ What was the impact of the prob lem on your practice? ■ What was the outcome of the prob lem? ■ How was the problem recognized? ■ How long did you have the prob lem before it was recognized? ■ How long after the problem was recognized did you attempt to re solve it?
F ig 2
Problem s encountered by task group members. Problem areas
% of problems described
No. of problems described
Management
107
33
Administrative / operational
136
42
81
25
324
100
Technical / clinical Total Table 1
problem solving, and outcome in terms of problem resolution. Task group members used different methods to identify different prob lems. Many problems were recognized by a recurring series of events; some were recognized by a single, often highly charged event, and some by a slow process of realization. Clinical problems appear to be easier to iden tify than nonclinical problems. Task group members think that dental school training and continuing educa tion give the dentist explicit standards of excellence for clinical performance. Dentists learn to match their work, or the work of others, against these per formance standards and to recognize deviations from the standard. Stan dards are usually not very clear in practice management and administra tion, and this was reflected by difficul ties in problem identification in these areas. Most task group members do not set explicit goals for performance standards for themselves in areas such as practice growth, productivity, and type of practice. Task group members varied in their ability to recognize problems in practice administration that were related to the ability to judge personal performance, staff perfor mance, or office emergency, compared with some expected standard.
Resources m entioned by task group members.
Types o f problem s Resources used (number of times mentioned) CO
f-i
Ö
QD O BO
a
O ^ ° Œ) - t+ H co
o
Type of problem
a ID -a w•
a
u
§ £ "3 o 2 a
S ^
LJ
>> -Ö
B CO
CO
a
.2 CO ’- g -
"S 0 Ö CO Ph r*
co
£ o
31 s
CD
a % 13 o tM u
ü £
13
a (D «
03
O a
Si
C CÜ "3
CL,
Management
24
24
35
38
13
Administrative I operational
31
41
30
37
14
Technical I clinical
13
17
17
20
5
7
4
Total
68
82
82
95
32
14
22
P ercent (av era ge fo r three types o f problem s)
_1
15.2
Table 2 872 ■ JADA, Vol. 103, December 1981
58.1
15
(IDH -a O
« o H
25
167
18 188 8
91
51 446
I
L.
26.7
100.0
Relatively fewer problems were men tioned in the technical I clinical area of dental practice than in other areas. Task group members suggested that clinical problems are easier for the practitioner to identify, and that more clearly defined and accessible re sources are available to assist in their resolution. Both dental school training and the support systems available to the practicing dentist contribute to identification and solution of clinical problems. Clinical skills and com petencies learned in dental school are directly translatable into problem solving strategies for practitioners. Continuing education courses, study clubs, society meetings, the informal network of peer associations, and the journal literature are all readily avail able resources that may be used in clin ical problem-solving, and all these re sources may be used in ways similar to those learned in dental school. Task group members also suggested
ARTICLES
that the entire area of practice man agement was one for which they were less well prepared by training. A l though practice administration is fre quently discus'sed in the dental litera ture as though it were a single area, task group members identified a large number of discrete problems, such as when to hire a new staff member. In many problem areas, the skills and competencies required for problem solving were not part of the dentist’s armamentarium. Specific resources for problem solving were sometimes d ifficult to identify; for example, means to identify information about, and evaluate the capability of, such professional support personnel as ac countants, lawyers, and practice man agement consultants.
Occurrence of problems in practice The majority of problems identified were described as first occurring within the first five years of practice. Problems in practice management and a d m in istratio n were p a rticu larly likely to be identified early (if iden tified at all), and many of these were identified virtually immediately on entry into practice. This finding corre sponds to the findings of surveys that have found younger dentists to be more interested in practice-oriented rather than clinically-oriented con tinuing education courses.10 Many problems occur repeatedly, for exam ple, expansion of facilities or staff. Others may occur at only one time, for example, selling a practice. Different types of practitioners had somewhat different problems. A l though the problems of rural practi tioners were similar to those of other practitioners, their problems appeared to be exacerbated by isolation from peers, suppliers, and other resources. Women practitioners identified spe cial problems in relating to patients and professional persons outside of the practice such as laboratory per sonnel, supply house representatives, and bankers. For women practitioners, their own attitudes and sense of par ticipation in the profession were also problem areas.
Solution stratégies Review of the individual problems identified by task group members in dicates that, in many problem areas, different resources or competencies may be used to solve a problem; how ever, many of the solution strategies described for individual problem areas involve similar processes of problem solving. Thus, when faced with simi lar problems, one practitioner may read independently in journals, dis cuss the problem with peers, and de velop some procedure or system suited to his or her office. Another practitio ner may consult an accountant, take a course in continuing education, and modify an existing procedure or sys tem to fit his or her office needs. The processes involved in both strategies include information gathering; train in g , advice, or assistance; and design and development. In attempting to resolve practice problems, task group members needed competence in the following areas. Problem identification. Practitio ners need to be able to discern the dif ference between expected events and actual events that occur in practice. They need to develop explicit or im plicit standards to evaluate their prac tices. An essential part in developing such standards involves setting per sonal and practice goals in areas such as productivity, patient load, income, practice growth, and style of practice; setting performance standards for staff, office systems, professional sup port, laboratory services, and the prac titioner in terms of clinical éfficiency and types and quality of services ren dered; and setting goals for patients in terms of patient performance, under standing, compliance, or acceptance of treatment. Information gathering. The practi tioner needs to learn how and where to gather inform ation necessary for decision-making and change. Communications. The practitioner must learn to be comfortable and effec tive in communications with staff, pa tients, and others external to the prac tice, and learn to develop effective communications procedures for con veying information to and assuring performance of patients, staff, dental laboratories, and others. Decision-making. The practitioner should learn to evaluate information
and make decisions related to the prac tice and to solicit and evaluate advice or assistance in decision making. Systems development and design. The practitioner needs skills in the ac tual design and implementation of forms, processes, policies, procedures, or equipment for use in the office. (
Discussion and conclusions The results of this study should be in terpreted with the understanding that it was designed as a pilot effort. The extent to which the views or experi ences o f the steering committee and task group members who participated in the study reflect the views or expe riences of practicing dentists in gen eral is not known. Also, it is possible that the particular characteristics of the workbooks could have limited in unknown ways the range and types of problems described by the task group members. In addition, the methods used in the study produced an enor mous amount of qualitative informa tion, which is not amenable to statisti cal analysis. Nevertheless, the study findings suggest a need to conduct more rigorous research on problem identification and solution strategies used in dental practice to confirm, re fine, and extend what has been found. The following tentative conclusions about problem identification in dental practice appear warranted from this study: —The majority of problems that are identified as problems by dental prac titioners are in the area of practice management and administration. —W ithin the area generally referred to as practice administration, a large number and variety of discrete prob lems can be identified. —A large number of problems first occur relatively early in the lifetime of a practice, within the first five years. — Rural and female practitioners appear either to experience different problems or to experience the same problems but in a different way. The following conclusions about problem-solving strategies used by practitioners are offered: — Dental professionals are active self-directed learners who are capable of responding to self-identified prob lems by planning and carrying out ac tivities necessary to resolve those problems.
Blandford—Dane : PROBLEMS IN DENTAL PRACTICE : STUDY FOR CONTINUING EDUCATION ■ 873
ART ICLES
— Solutions to problems in dental practice frequently involve the practi tioner in the identification and use of several resources. — Problem solution often involves both formal and informal resources, with use of informal resources occur ring most frequently. — Solution strategies for problems in dental practice range from highly planned use of resources to solve well-defined problems to virtually serendipitous solutions to situations that may not even be recognized as problems by the practitioner. Some of these findings are curious and, if validated by further research, suggest some interesting directions for continuing dental education. First, the distinct emphasis by study participants on nonclinical problems rather than clinical problems was con sistent in all task groups. It is not that clinical problems do not exist; rather task group members thought that clin ical difficulties are not as frequently viewed as problems. As a result, dis cussions in all meetings concerned the need for more emphasis on problems of practice administration both in doc toral training and continuing educa tion. These findings suggest that problem-oriented CDE may be more useful for planning courses in practice administration than in courses in clin ical dentistry. Second, the unique and pressing problems of new practitioners and, to a lesser degree, rural and female practi tioners suggest more targeted continu ing education activities designed to address those problems. Much of con tinuing education today appears to as sume a relatively undifferentiated mass of practitioners, all with the same CDE needs. Results from this study suggest otherwise. Third, the frequent use of informal resources in solving practice problems suggests that more effective integra tion of formal and informal CDE re sources may be useful. For example, more effective and systematic use of study clubs may be helpful. Likewise, scheduling of informal discussion op
874 ■ JADA, Vol. 103, December 1981
portunities during formal CDE courses may be an effective strategy. Fourth, many, and perhaps most, practitioners are struggling to solve practice problems in their own unique and inform al ways. This fin d in g suggests that training in methods for effective problem solving and ways of identifying and using resources for solving practice problems may con tribute importantly to practice effi ciency and effectiveness. Finally, many task group members indicated that information necessary to solve particular problems was not always available or was not available in a timely manner. Yet many informa tion resources are already available and were referred to by task group members. These findings suggest that a clearinghouse that makes informa tion widely available on a variety of practice problems might be useful. Such a resource could go beyond col lections of published literature to in clude examples of useful materials such as recall systems, office proce dure manuals, or accounting systems.
Summary This paper describes the results of a one-year study designed as a prelimi nary inquiry into the natural history of problems in dental practice. The results indicate that nonclinical practice problems are identified as problems more frequently than clini cal problems and are more difficult for practitioners to resolve. Different types of problems occur at different times in the lifetime of a practice, with the greatest number of problems oc curring in the early years of practice. Solution strategies to practice prob lems frequently involve the use of sev eral resources, frequently a mix of for mal resources, such as education, with informal resources, such as peer con sultation or independent study. The most frequently mentioned resource in problem solving was peer consulta tion; continuing dental education was the fourth most frequently mentioned resource.
The study findings have implica tions for the content and organization of continuing dental education. There may be effective ways to target CDE to specific audiences, to integrate formal and informal learning experiences, and to improve the availability of in formation on how to solve problems in dental practice. Practice administra tion may be one area that would bene fit particularly from efforts to develop problem-oriented CDE experiences.
This research was supported by contract no. HRA 232-79-0056, awarded by the Division of Dentistry, Healdl Resources Administration, US Department of Health and Human Services, to Policy Research, Inc. The authors thank Irene Jillson, president, and Christopher Rubino, research assistant, Policy Research, Inc; Malcolm Knowles and Roy Lin dahl, project consultants, for their input and par ticipation; and the participants in the study. Mr. Blandford is deputy chief, Professional Education Branch, Division of Dentistry, Health Resources Administration, US Department of Health and Human Services, Hyattsville, M d 20782; Mr. Dane is senior research associate, Pol icy Research, Inc, Baltimore. Address requests for reprints to Mr. Blandford. 1. Pavone, B.W. What should boards do with d entists whose com petence is q uestio ned through peer review or . . . J A m Coll Dent 43(4):232-237, 1976. 2. Francis, R.R. Competency of health profes sionals: an approach for continuing education. JADA 92:1119-1123, 1976. 3. Tough, A. The adult’s learning projects. O n tario Institute for Studies in Education. Ontario, Canada, 1971. 4. Knowles, M. The adult learner: a neglected species. Houston, Gulf Publishers, 1973. 5. Libby, G.N.; Weiswig, M.H.; and Kirk, K.W. Help stamp out mandatory continuing education. JADA 233:797, 1975. 6. Knox, A.B. Continuing education of phar macists. J Am Pharm Assoc N S 15(8), 1975. 7. Stein, L. Adult learning principles: the ind i vidual curriculum and nursing leadership. J Cont Ed Nurs 2(6):10, 1971. 8. Tibbies, L. Theories of adult education: im plication for developing a philosophy for con tinuing education in nursing. J Cont Ed Nurs 8(4):25-28,1977. 9. Knowles, M. Continuing education: the role of a professional organization, a theoretical framework. Prof Med Asst, May-June, 1978. 10. Cafferata, G.L., and others. Continuing education: attitudes, interests, and experiences of practicing dentists. J Dent Ed 39(12):793-800, 1975.
f
)
ART1CLES
Problems in dental practice: a pilot study for continuing education D o n ald H. B lan d fo rd , M A J. K en Dane
Continuing education is moving away from the traditional subject-m atter orientation. This study assesses the potential fo r problem -oriented continuing dental education p rogram s to h elp practitioners solve the problem s they encounter in practice.
T
he continuing professional com petence of the dental practitioner and the means of assuring that competence have long been a focus of attention for dental professional organizations and state and federal agencies. Whereas a variety of specific mechanisms for as suring competence have been pro posed, both current methods and suggested alternatives incorporate continuing dental education (CDE) as a primary tool for maintaining compe tency. Local and national professional o r g a n iz a tio n s have e sta b lis h e d m inim um CDE requirements for their members; several state agencies have established m inim um requirements in CDE as a condition of relicensure. Some have recommended more rigor ous systems to assure competency, such as peer review through profes sional standards review organizations and prescribed retraining in areas of deficiency.1
Recently, attention has been turned toward the continuing education pro cess and particularly toward the rela t io n s h ip b e tw e e n e d u c a t io n a l methods and what an adult learns. Francis2 has called for a reorientation of continuing dental education toward a self-directed, problem-oriented ap proach. This approach, based on re search3and theories of adult learning,4 suggests that adults learn best when education is directly relevant to the problems that they are experiencing. The problem-oriented approach to education is offered as a contrast to the current approach of CDE, which is or ganized primarily around subject mat ter categories such as crown and bridge, endodontics, and practice ad ministration. The interest in problem-oriented continuing education transcends den tistry and is virtually a movement in the health professions. Practitioners in
m edicine,5 pharmacy,6 nursing,7,8, and the auxiliary health professions9 have all advocated a problem-oriented approach to continuing professional education. The implementation of at least some problem-oriented continuing educa tion, if only on a pilot basis, may be de sirable both because of its theoretical promise and because it may afford an opportunity to examine more directly the impact of CDE on professional competency. However, there are sev eral fu n d a m e n tal barriers to im plementation at the present time. First, the lack of systematic knowledge about the types of problems faced by dentists in practice makes it difficult to identify appropriate areas for course development. Second, there is little systematic knowledge about the cur rent problem-solving behavior by den tists in practice. Such knowledge is necessary for the developm ent of courses that will build on the profes sional competencies and the patterns of resource use already in place. The present study was designed to investigate the natural history of prob lem identification and problem solv ing in dentistry. The specific purposes of the study were to identify and analyze clinical and nonclinical prob lems commonly met by general dental practitioners during the lifetime of a dental practice and to identify and analyze the strategies and resources commonly used by dentists in resolv ing these problems. Information re sulting from the study should facilitate the development and implementation of problem-oriented approaches to CDE.
Study methods The study involved nearly 50 dentists and dental practice consultants, who were organized into a steering com m itte e charg e d w ith p r o v id in g methodologic and analytic assistance JADA, Vol. 103, December 1981 ■ 869
ART ICLES
throughout the study; two project con sultants, one expert in continuing den tal education, the other in adult educa tion, who provided technical advice and assistance throughout the study; and four task groups composed of full-time dental practitioners and den tal practice consultants, who provided specific information on clinical and nonclinical problems in dental prac tice and the strategies and resources used to resolve these problems.
Selection of participants The steering committee was composed of six professionals: four practicing dentists and two dental practice man agement consultants. The members were selected to assure a wide range of private practice experience and con sulting experience and a high level of conceptual ability. The four task groups were each composed of seven dental practition ers and two dental practice consul tants. The 36 task group members were selected from 125 nominations pro vided by dental professional organiza tions, dental schools, steering com mittee members, and other sources. Task group members were assigned to a particular group based on certain c h a ra c te ristic s . A m ong a ll task groups, efforts were made to vary the m embers’ characteristics, such as length of time in practice, geographic location, and type of consultant prac tice (for example, private consultant, university-based consultant, and man agement-firm based consultant). Thus, the task groups were intended to be a deliberate sample of dental practitioners and practice consultants from around the country. Both indi vid ually and collectively, the task groups brought together dental practi tioners and consultants whose experi ence covered a broad range of per sonal, professional, and practice characteristics.
Study design Workbooks and structured group meetings were used to collect data. The steering committee met twice dur ing the formative stages of the study and once after the task group meetings to assist in developing the materials and methodology for obtaining infor mation from task group members, de
870 ■ JADA, Vol 103, December 1981
veloping the process for obtaining task group nominations and selecting task group members, and advising on the analysis of data and presentation of re sults. A behavioral definition of dental practice problems was developed and adopted. This definition relates the perception of a problem to its resolu tion: A problem in dental practice is an event, or a series of events, per ceived by a dentist as having an adverse impact on the quality of care provided to patients or on the efficient operation of the dental practice. Either the seriousness or the recurring nature of the event suggests the need to alter the be haviors or circumstances that produce the events. In light of this definition, the failure of a single patient to arrive for a sched uled appointment probably would not be viewed as a problem; however, the recurring failure of patients to meet appointm ents probably w ould be. Similarly, paperwork may be a general problem, but a more specifically iden tifiable problem may be the appropri ate completion of insurance forms. Additionally, some individual events may be so important that they are im mediately perceived as problems. For instance, the failure of appropriate staff to respond to an in-office emer gency may be so important as to re quire immediate resolution. A classification scheme for prob lems was developed by the steering committee for use in the design of task group workbooks. The classification scheme, shown in Figure 1, enables the identification of indiyidual prob lems in three major areas and 13 prob lem categories, and may be the first scheme that attempts to classify the full range and complexity of dental practice activities. One workbook fo cused on the identification and de scription of problems; the other, on the description of solution strategies and resources for problem solving. The questions in the workbooks were based on the problem classification scheme and included examples of general problems associated with each problem area. Task group members completed the workbooks by identify ing their own problems and answering a series of questions about each prob lem (Fig 2).
Four task group meetings were held during May and June 1980. Two task groups focused primarily on problem identification and description; two task groups focused on solution strate gies. A ll four meetings were con ducted using a similar format. A pre meeting workbook was mailed to task group members approximately two weeks before each meeting. Members completed and returned the work books, which were then transcribed and organized to serve as points of de parture for discussion at the meetings. The meetings were structured to en courage participation and contribu tions by all task group members.
Results Types of problems identified Thirty-three task group members completed and returned workbooks. A total of 324 individual problems were described, and details of either prob lem identification or the strategies and resources used in problem solving were provided. Table 1 shows the distribution of problems among the three problem areas. About a third of the problems involved the human relations aspect of dental practice, problems involving patients, staff, external consultants, and the practitioner’s own psyche. More than 40% of problems described concerned management of the ad ministrative and operational aspects of practice. These are primarily systems management problems. Only a fourth of the problems described concerned technical I clinical difficulties. In this study, the bulk of problems described by task group members were practice administration problems (75%), rather than clinical problems (25%).
Problem-solving resources Table 2 summarizes the number of times that specific problem-solving re sources were mentioned. The resource most frequently mentioned was peer co n sultation . In d e p e n d e n t study (journal reading) and use of consul tants or other professional support (practice management consultants, lawyers, and accountants) received the same number of mentions and were the next most frequently noted re sources. CDE, including both schoolbased continuing education and den-
A R T IC L E S
Taxonomy of problems in dental practice MANAGEMENT Problems that arise as a result of, or incidental to, human interactions, including interactions with staff, patients, or other persons who come in contact with the practice.
Problem area categories Patient m anagem ent problems result from in teractions of patients with the practitioner or staff, including problems of patient motivation and compliance. P ersonnel m anagem ent problems result from interactions of practitioner with his or her staff, including all phases of hiring, retention, dis missal, and motivation of employees. Office m anagem ent problems result from lack of coordination between practitioner, staff, and other support, including problems of patient scheduling and the flow os staff, practitioner, and patients. Personal m anagem ent problems arise from the practitioner’s attitudes, values, and capabilities with respect to the professional role.
ADMINISTRATIVE/OPERATIONAL Problems that relate to office coordination and management, excluding human interactions, including problems of paperwork, overall effi ciency, design of office, and business and prac tice management concerns.
Problem area categories Office m anagem ent problems result from deci sions about the conduct and procedures used in the management of the practice, considerations of the practice styel, and marketing procedures. Environm ental m anagem ent problems arise
from design of office and facility spaces, and the work environment and its hazards. Clinical efficiency problems result from the in effective use of equipment, time, dental prod ucts, or coordination with professional support. Business m anagem ent problems involve cash flow, record keeping, and accounting, and deci sions about fees, billing, recall systems, insur ance coverages, credit, collection, and office policies. Clinical process m anagem ent problems result from practice style, practitioner needs, or in adequate clinical skills.
TECHNICAL/CLINICAL Problems that result from treatment of the pa tient, including all phases of patient treatment from the patient’s history to follow-up treatment procedures.
Problem area categories History and examination problems result from inadequate records of information relevant to the patient. Inadequate record keeping can lead to diagnosis, treatment, and follow-up prob lems. Diagnosis problems result from the process of analyzing patient problems and providing a diagnosis. Treatment problems result from decisions con cerning treatment procedures and possible problems during treatment. Follow-up problems result from either postop erative complications or decisions by the practi tioner concerning follow-up treatment.
Fig 1
tal society meetings, was the fourth most frequently mentioned problem solving resource. Review of the indi vidual problem descriptions indicates that several resources were used in solving a majority of the problems. The use of experts', peers, and inde pendent study together received a clear majority of mentions as resources used to solve problems in dental prac tice. Interestingly, CDE and dental so
ciety meetings accounted for only 15% of the mentions as resources for solv ing practice problems. These results clearly suggest that most problems in dental practice are solved outside the formal CDE framework.
Problem identification All problems identified were reviewed and grouped on the basis of similarity,
resulting in the specification of 86 separate problems for analysis pur poses: 31 problems in the area of man agement, 27 in the administrative I op erational area, and 28 in the technical I clinical area. For each problem, sum maries were prepared, w hich inte grated all available information on problem identification, point of occur rence in practice, resources used to re solve the problem, strategies used in
Blandford-Dane : PROBLEMS IN DENTAL PRACTICE STUDY FOR CONTINUING EDUCATION ■ 871
Types o f questions in w orkbooks Problem definition workbooks
Solution strategies workbooks ■ Describe the problem. ■ What resources did you use to re solve the problem? ■ What strategy (pattern of use of re sources) did you use to resolve the problem? ■ How much planning was involved in solving the problem? ■ What was the outcome of the prob lem? ■ Describe your use of the following resources in resolving the problem: continuing education courses, dental practice consultants, independent study.
■ Describe the problem. ■ At what point in practice did the problem first occur? ■ What was the impact of the prob lem on your practice? ■ What was the outcome of the prob lem? ■ How was the problem recognized? ■ How long did you have the prob lem before it was recognized? ■ How long after the problem was recognized did you attempt to re solve it?
F ig 2
Problem s encountered by task group members. Problem areas
% of problems described
No. of problems described
Management
107
33
Administrative / operational
136
42
81
25
324
100
Technical / clinical Total Table 1
problem solving, and outcome in terms of problem resolution. Task group members used different methods to identify different prob lems. Many problems were recognized by a recurring series of events; some were recognized by a single, often highly charged event, and some by a slow process of realization. Clinical problems appear to be easier to iden tify than nonclinical problems. Task group members think that dental school training and continuing educa tion give the dentist explicit standards of excellence for clinical performance. Dentists learn to match their work, or the work of others, against these per formance standards and to recognize deviations from the standard. Stan dards are usually not very clear in practice management and administra tion, and this was reflected by difficul ties in problem identification in these areas. Most task group members do not set explicit goals for performance standards for themselves in areas such as practice growth, productivity, and type of practice. Task group members varied in their ability to recognize problems in practice administration that were related to the ability to judge personal performance, staff perfor mance, or office emergency, compared with some expected standard.
Resources m entioned by task group members.
Types o f problem s Resources used (number of times mentioned) CO
f-i
Ö
QD O BO
a
O ^ ° Œ) - t+ H co
o
Type of problem
a ID -a w•
a
u
§ £ "3 o 2 a
S ^
LJ
>> -Ö
B CO
CO
a
.2 CO ’- g -
"S 0 Ö CO Ph r*
co
£ o
31 s
CD
a % 13 o tM u
ü £
13
a (D «
03
O a
Si
C CÜ "3
CL,
Management
24
24
35
38
13
Administrative I operational
31
41
30
37
14
Technical I clinical
13
17
17
20
5
7
4
Total
68
82
82
95
32
14
22
P ercent (av era ge fo r three types o f problem s)
_1
15.2
Table 2 872 ■ JADA, Vol. 103, December 1981
58.1
15
(IDH -a O
« o H
25
167
18 188 8
91
51 446
I
L.
26.7
100.0
Relatively fewer problems were men tioned in the technical I clinical area of dental practice than in other areas. Task group members suggested that clinical problems are easier for the practitioner to identify, and that more clearly defined and accessible re sources are available to assist in their resolution. Both dental school training and the support systems available to the practicing dentist contribute to identification and solution of clinical problems. Clinical skills and com petencies learned in dental school are directly translatable into problem solving strategies for practitioners. Continuing education courses, study clubs, society meetings, the informal network of peer associations, and the journal literature are all readily avail able resources that may be used in clin ical problem-solving, and all these re sources may be used in ways similar to those learned in dental school. Task group members also suggested
ARTICLES
that the entire area of practice man agement was one for which they were less well prepared by training. A l though practice administration is fre quently discus'sed in the dental litera ture as though it were a single area, task group members identified a large number of discrete problems, such as when to hire a new staff member. In many problem areas, the skills and competencies required for problem solving were not part of the dentist’s armamentarium. Specific resources for problem solving were sometimes d ifficult to identify; for example, means to identify information about, and evaluate the capability of, such professional support personnel as ac countants, lawyers, and practice man agement consultants.
Occurrence of problems in practice The majority of problems identified were described as first occurring within the first five years of practice. Problems in practice management and a d m in istratio n were p a rticu larly likely to be identified early (if iden tified at all), and many of these were identified virtually immediately on entry into practice. This finding corre sponds to the findings of surveys that have found younger dentists to be more interested in practice-oriented rather than clinically-oriented con tinuing education courses.10 Many problems occur repeatedly, for exam ple, expansion of facilities or staff. Others may occur at only one time, for example, selling a practice. Different types of practitioners had somewhat different problems. A l though the problems of rural practi tioners were similar to those of other practitioners, their problems appeared to be exacerbated by isolation from peers, suppliers, and other resources. Women practitioners identified spe cial problems in relating to patients and professional persons outside of the practice such as laboratory per sonnel, supply house representatives, and bankers. For women practitioners, their own attitudes and sense of par ticipation in the profession were also problem areas.
Solution stratégies Review of the individual problems identified by task group members in dicates that, in many problem areas, different resources or competencies may be used to solve a problem; how ever, many of the solution strategies described for individual problem areas involve similar processes of problem solving. Thus, when faced with simi lar problems, one practitioner may read independently in journals, dis cuss the problem with peers, and de velop some procedure or system suited to his or her office. Another practitio ner may consult an accountant, take a course in continuing education, and modify an existing procedure or sys tem to fit his or her office needs. The processes involved in both strategies include information gathering; train in g , advice, or assistance; and design and development. In attempting to resolve practice problems, task group members needed competence in the following areas. Problem identification. Practitio ners need to be able to discern the dif ference between expected events and actual events that occur in practice. They need to develop explicit or im plicit standards to evaluate their prac tices. An essential part in developing such standards involves setting per sonal and practice goals in areas such as productivity, patient load, income, practice growth, and style of practice; setting performance standards for staff, office systems, professional sup port, laboratory services, and the prac titioner in terms of clinical éfficiency and types and quality of services ren dered; and setting goals for patients in terms of patient performance, under standing, compliance, or acceptance of treatment. Information gathering. The practi tioner needs to learn how and where to gather inform ation necessary for decision-making and change. Communications. The practitioner must learn to be comfortable and effec tive in communications with staff, pa tients, and others external to the prac tice, and learn to develop effective communications procedures for con veying information to and assuring performance of patients, staff, dental laboratories, and others. Decision-making. The practitioner should learn to evaluate information
and make decisions related to the prac tice and to solicit and evaluate advice or assistance in decision making. Systems development and design. The practitioner needs skills in the ac tual design and implementation of forms, processes, policies, procedures, or equipment for use in the office. (
Discussion and conclusions The results of this study should be in terpreted with the understanding that it was designed as a pilot effort. The extent to which the views or experi ences o f the steering committee and task group members who participated in the study reflect the views or expe riences of practicing dentists in gen eral is not known. Also, it is possible that the particular characteristics of the workbooks could have limited in unknown ways the range and types of problems described by the task group members. In addition, the methods used in the study produced an enor mous amount of qualitative informa tion, which is not amenable to statisti cal analysis. Nevertheless, the study findings suggest a need to conduct more rigorous research on problem identification and solution strategies used in dental practice to confirm, re fine, and extend what has been found. The following tentative conclusions about problem identification in dental practice appear warranted from this study: —The majority of problems that are identified as problems by dental prac titioners are in the area of practice management and administration. —W ithin the area generally referred to as practice administration, a large number and variety of discrete prob lems can be identified. —A large number of problems first occur relatively early in the lifetime of a practice, within the first five years. — Rural and female practitioners appear either to experience different problems or to experience the same problems but in a different way. The following conclusions about problem-solving strategies used by practitioners are offered: — Dental professionals are active self-directed learners who are capable of responding to self-identified prob lems by planning and carrying out ac tivities necessary to resolve those problems.
Blandford—Dane : PROBLEMS IN DENTAL PRACTICE : STUDY FOR CONTINUING EDUCATION ■ 873
ART ICLES
— Solutions to problems in dental practice frequently involve the practi tioner in the identification and use of several resources. — Problem solution often involves both formal and informal resources, with use of informal resources occur ring most frequently. — Solution strategies for problems in dental practice range from highly planned use of resources to solve well-defined problems to virtually serendipitous solutions to situations that may not even be recognized as problems by the practitioner. Some of these findings are curious and, if validated by further research, suggest some interesting directions for continuing dental education. First, the distinct emphasis by study participants on nonclinical problems rather than clinical problems was con sistent in all task groups. It is not that clinical problems do not exist; rather task group members thought that clin ical difficulties are not as frequently viewed as problems. As a result, dis cussions in all meetings concerned the need for more emphasis on problems of practice administration both in doc toral training and continuing educa tion. These findings suggest that problem-oriented CDE may be more useful for planning courses in practice administration than in courses in clin ical dentistry. Second, the unique and pressing problems of new practitioners and, to a lesser degree, rural and female practi tioners suggest more targeted continu ing education activities designed to address those problems. Much of con tinuing education today appears to as sume a relatively undifferentiated mass of practitioners, all with the same CDE needs. Results from this study suggest otherwise. Third, the frequent use of informal resources in solving practice problems suggests that more effective integra tion of formal and informal CDE re sources may be useful. For example, more effective and systematic use of study clubs may be helpful. Likewise, scheduling of informal discussion op
874 ■ JADA, Vol. 103, December 1981
portunities during formal CDE courses may be an effective strategy. Fourth, many, and perhaps most, practitioners are struggling to solve practice problems in their own unique and inform al ways. This fin d in g suggests that training in methods for effective problem solving and ways of identifying and using resources for solving practice problems may con tribute importantly to practice effi ciency and effectiveness. Finally, many task group members indicated that information necessary to solve particular problems was not always available or was not available in a timely manner. Yet many informa tion resources are already available and were referred to by task group members. These findings suggest that a clearinghouse that makes informa tion widely available on a variety of practice problems might be useful. Such a resource could go beyond col lections of published literature to in clude examples of useful materials such as recall systems, office proce dure manuals, or accounting systems.
Summary This paper describes the results of a one-year study designed as a prelimi nary inquiry into the natural history of problems in dental practice. The results indicate that nonclinical practice problems are identified as problems more frequently than clini cal problems and are more difficult for practitioners to resolve. Different types of problems occur at different times in the lifetime of a practice, with the greatest number of problems oc curring in the early years of practice. Solution strategies to practice prob lems frequently involve the use of sev eral resources, frequently a mix of for mal resources, such as education, with informal resources, such as peer con sultation or independent study. The most frequently mentioned resource in problem solving was peer consulta tion; continuing dental education was the fourth most frequently mentioned resource.
The study findings have implica tions for the content and organization of continuing dental education. There may be effective ways to target CDE to specific audiences, to integrate formal and informal learning experiences, and to improve the availability of in formation on how to solve problems in dental practice. Practice administra tion may be one area that would bene fit particularly from efforts to develop problem-oriented CDE experiences.
This research was supported by contract no. HRA 232-79-0056, awarded by the Division of Dentistry, Healdl Resources Administration, US Department of Health and Human Services, to Policy Research, Inc. The authors thank Irene Jillson, president, and Christopher Rubino, research assistant, Policy Research, Inc; Malcolm Knowles and Roy Lin dahl, project consultants, for their input and par ticipation; and the participants in the study. Mr. Blandford is deputy chief, Professional Education Branch, Division of Dentistry, Health Resources Administration, US Department of Health and Human Services, Hyattsville, M d 20782; Mr. Dane is senior research associate, Pol icy Research, Inc, Baltimore. Address requests for reprints to Mr. Blandford. 1. Pavone, B.W. What should boards do with d entists whose com petence is q uestio ned through peer review or . . . J A m Coll Dent 43(4):232-237, 1976. 2. Francis, R.R. Competency of health profes sionals: an approach for continuing education. JADA 92:1119-1123, 1976. 3. Tough, A. The adult’s learning projects. O n tario Institute for Studies in Education. Ontario, Canada, 1971. 4. Knowles, M. The adult learner: a neglected species. Houston, Gulf Publishers, 1973. 5. Libby, G.N.; Weiswig, M.H.; and Kirk, K.W. Help stamp out mandatory continuing education. JADA 233:797, 1975. 6. Knox, A.B. Continuing education of phar macists. J Am Pharm Assoc N S 15(8), 1975. 7. Stein, L. Adult learning principles: the ind i vidual curriculum and nursing leadership. J Cont Ed Nurs 2(6):10, 1971. 8. Tibbies, L. Theories of adult education: im plication for developing a philosophy for con tinuing education in nursing. J Cont Ed Nurs 8(4):25-28,1977. 9. Knowles, M. Continuing education: the role of a professional organization, a theoretical framework. Prof Med Asst, May-June, 1978. 10. Cafferata, G.L., and others. Continuing education: attitudes, interests, and experiences of practicing dentists. J Dent Ed 39(12):793-800, 1975.