By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

 

College campuses are in the media spotlight these days, as they are roiled by competing views on the Israel-Hamas war and how universities should respond to world events. On some campuses, including NYU’s, students featured prominently in these debates, raising questions not just about what constitutes free speech but also about what it means to be a professional.

For decades, dental educators have contemplated how best to prepare students for practice as a professional. It’s one thing to teach students about ethics. It’s quite another to socialize them to be ethical professionals, and the challenges of preparing students for their future roles seem to be increasing by the day.

Are dental schools doing enough to ensure their students understand that being a licensed professional is a privilege that comes with certain duties? Every time I speak at a dental school’s commencement exercise or a white coat ceremony, I make this point: People will come to us in pain and suffering with an expectation that we will treat them to the best of our ability whatever we may think about them as individuals. I’m sure the audience always hears me, but is the message getting through?

 

21st Century Challenges

Events last year at Wake Forest University offer a case in point. A medical student bragged on social media about missing a patient’s vein after the patient questioned their display of gender pronouns. The university concluded that the student did not harm the patient intentionally but placed them on extended leave for their inappropriate use of social media.

I recently discussed the incident with NYU Dean Charles Bertolami, DDS, DMedSc. “Whatever happened in the clinic, it ended up translating into a public perception that you can’t trust doctors,” he said. The student made a public apology for their unprofessional conduct and its poor reflection on the school, but the damage to Wake Forest’s and the student’s reputations had already been done.

I also spoke with another longtime colleague of mine, Pamela Zarkowski, JD, MPH, who serves as provost and vice president for academic affairs at the University of Detroit Mercy. She is internationally recognized for her scholarship on professional, legal, and ethical issues related to the health professions. “I think students aren’t really clear about what constitutes freedom of speech,” she said.

Students aren’t the only ones who challenge professional norms in the name of free speech, as the New York Times reported in December when the chancellor of the University of Wisconsin lost his job for posting pornographic videos. The way that Pam responded is key: “One of the challenges as we go forward will be trying to educate everybody about what is legally protected speech and what is speech that reflects well on professionals.”

 

Ground Zero: Cheating

Discussions of ethics in dental education are often rooted in a more parochial concern: cheating. This ethical lapse is probably as old as academic grading, but smartphones, online apps, and most recently, generative AI tools, complicate the picture. Charles’ interest in ethics education began at the University of California, San Francisco (UCSF) School of Dentistry, where he served as dean when digital technologies were being widely integrated in classrooms. The outcome of an early online test at UCSF revealed evidence of dishonesty. When Charles received the news, he remembers thinking, “Aren’t our students taking courses in ethics? How does this happen?”

Academic dishonesty has also been reported at the nation’s military academies and at other dental schools. In seeking to understand why, Charles observed that conventional ethics courses informed students about ethics but rarely spurred the kinds of insights that might prompt behavior change. In a widely read 2004 article, he concluded that dental school ethics courses were “inadequate in content and form” and proposed the need to “cultivate an introspective orientation to professional life” as a possible solution.

Although ethics education was clearly falling short, it wasn’t for lack of trying. In 2009, the American Dental Education Association (ADEA) released a statement on professionalism in dental education, and a 2011 survey by the American Society for Dental Ethics (ASDE) found that 80% of dental schools offered at least one formal course on ethics. Many programs incorporated a broad range of content, and teaching methods included case-based learning, small group discussions, and reflective writing.

 

Necessary but not Sufficient

Pam noted these improvements when she served as a site visitor for the Commission on Dental Accreditation (CODA). She says many grading rubrics used by dental schools on the clinic floor included students’ professionalism and judgment in addition to their clinical competence. But she worries that schools may still fall short, doing enough to meet accreditation standards but not significantly impacting students’ thinking or behavior. She has seen too many idealistic students become cynical over time. “Dental School presents some challenging realities,” she observes.

Pam offered some examples:

• A staff member gossips about a patient or mocks their accent.
• A preceptor tells a student to fudge a patient’s blood pressure in the medical record so they can move ahead with a procedure.
• A D3 student fails to report a patient who is sexually or ethnically harassing a D4 student in clinic because the D4 needs the patient to complete a graduation competency.

I’ve seen similar ethical lapses over the years and often fear we are on a slippery slope. Violations of professional conduct create an institutional climate from which students learn as much or more than they do in formal ethics courses about what is acceptable in practice. This contrast can lead to cynicism and demoralization, but that doesn’t mean we should give up. Research shows that without formal instruction, the moral development of professional school students either fails to progress or erodes as they move through their programs.

 

What’s Next for Ethics Education?

To arrest the slide down the slippery slope, we need to become more effective at socializing our students to their professional roles and responsibilities. Recommendations include:

• Integrating ethics education throughout the curriculum, including in the clinical years,
• Assessing professionalism on an ongoing basis,
• Service-learning opportunities that stimulate reflection,
• Encouraging ongoing self-reflection
• Creating faculty development programs related to ethics and professionalism,
• Ensuring that professionalism is modeled as well as taught, and
• Addressing ethical challenges within the institutional culture so that patient and student interests do not conflict.

We might also look to the other health professions for inspiration. Medical students at the University of Rochester School of Medicine and Dentistry engage in a peer assessment process that appears to enhance students’ awareness of their professional behavior.

Pam is part of a team that will soon be fielding another ASDE survey to gauge the status of ethics education today. Here at NYU Dentistry, they’ll find our students studying ethics right out of the gate. Charles teaches our 19-session introductory course and offers small group seminars to interested D2, D3, and D4 students. The program takes full advantage of classroom technology and game theory problems to make the ideas stick. He especially likes the ultimatum bargaining game, in which half the class must decide how to share an imaginary $100 windfall with their less fortunate peers. “Seventy percent of the students offer the fairest possible amount, a 50/50 split,” Charles reports, “however, 3½% of our students offer one dollar. Because we use an anonymous audience response system, those students immediately see how different they are from their peers,” he says, and gain insight and self-awareness.

In a subsequent experiment, the imaginary $100 is awarded to half the students based on an earned but unrelated property entitlement (a grade point average in the upper half of the class). In this scenario, Charles says, generosity declines significantly. This finding aligns with research on which drivers are least likely to yield at a four-way stop—those in the most expensive cars.

Do these thought experiments change student behavior? Charles readily admits that he doesn’t know. “But our graduates are going to be folks that are in an affluent group with a title, a state license, and a degree from a prestigious university,” he argues. “All those things push toward the greed end of the spectrum, so we need to try to balance that if we can.”

I agree. Our commitment to graduating health professionals who understand that a license to practice comes with responsibilities as well as privileges must be unwavering. While maintaining high expectations of our students, we might also show them some empathic understanding. Earlier generations were able to make mistakes—socially as well as academically—and even fail spectacularly, and not have their every indiscretion immortalized in social media. Let’s remember that human beings are works in progress, especially in the first few decades of their lives, and provide them with environments as well as instruction that cultivates their best instincts. Students, their future patients, and our professions will benefit.