European Journal of Dental Education ISSN 1396-5883

A patient-centred approach to teaching and learning

in dental student clinical practice
H. M. Eriksen, J. Bergdahl and Maud Bergdahl
Institute of Clinical Dentistry, Medical Faculty, University of Tromsø, Tromsø, Norway

Keywords Abstract
oral health; dental curriculum; oral ecosystem.
A patient-centred clinical teaching profile in the undergraduate dental curriculum at
Correspondence The University of Tromsø is described. This teaching profile implies that treatment
Prof. Harald M. Eriksen planning is primarily based on the patients’ perceived needs and the students are
Institute of Clinical Dentistry trained to retrieve information from the patients in this context. The role of the clini-
Medical Faculty cal instructor is primarily as a facilitator rather than an expert. The ‘best interest of
University of Tromsø the patient’ is not always easy to disclose and consequences related to the patients’
Tromsø 9037 levels of understanding, students competence, educational challenges and professional
Norway ethics are topics for discussion through the clinical education programme.
Tel: +47 77649103
e-mail: harald.eriksen@fagmed.uit.no

Accepted: 7 February, 2008

doi:10.1111/j.1600-0579.2008.00518.x

element in the overall shaping of minds and attitudes of

Introduction
For a dental student, clinical learning is principally centred on
guided provision of patient care. In this provision, dental
students and clinical teachers interact in close relationship
which is perceived as a key element in developing student
clinical skills (1, 2). Central in the clinical learning environ-
ment is the patient with her/his needs, demands, values and
expectations (3) and comprehensive retrieval of information
from the patient including recording of signs and symptoms
is an essential requirement in the treatment planning process.
However, this recording has traditionally acted more as an
important feature for professional treatment planning than
for proper consideration of the patients’ needs and values
(1, 2, 4).
In a committee report on the future of dental education
from The American Institute of Medicine (4), considerable
emphasis was put on the transition from traditional specialist-
directed treatment to comprehensive, patient-centred care. The
traditional model is characterised by a specialist role model,
student-centred instruction, segmented patient care with focus
on procedures and numerical requirements. In contrast, the
comprehensive care model has a generalist role model with
patient-centred education, evaluation and management focus
and qualitative requirements applying criteria of competence
for student evaluation (4, 5).
Dental students’ development of cultural competence and
social responsibility is recognised by educators as an important
modern dental practitioners (5). The role of the patient is
fundamental for the development of such knowledge, skills and
attitudes. Yet training modalities to achieve these competencies
are not clearly defined, and outcome measures are elusive
(5, 6).
There are marked differences between a specialist-conducted
and a patient-centred treatment planning process. Should each
patient attending the dental student clinic primarily serve
educational purposes defined by the teaching staff or should
the patients’ preferences serve as a major guideline in the
clinical education process? In the recommendations from the
committee on the future of dental education (4), patient-centred
comprehensive care should be the norm and patients’ prefer-
ences and their social, economic and emotional circumstances
should be sensitively considered. What are the educational
consequences of choosing this patient-centred position as a
guideline for the dental curriculum?
The degree of patient involvement in the clinical teaching
process may be categorised at different levels. In his book about
‘The reflective practitioner’ (7) Schön differentiates between the
traditional, authoritarian- and the reflective practitioner learn-
ing in action, strongly advocating the latter position. Emanuel
and Emanuel (8) present four models of the physician-patient
relationship going from the authoritarian (paternalistic) to
the interpretive and deliberative model reflecting increasing
concern for the patients’ values and integrity in the treatment
planning process.

170 Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Eriksen et al.
In the present publication focusing on the design of dental
students’ clinical training we want to limit our discussion to
the following three positions:
l The patients are primarily serving the teaching goals of the
student clinic. Dental treatment is decided by specialists and
performed in a segmented setting primarily based on the
detailed needs of the student. The patient acts as a ‘supplier’ of
clinical conditions necessary for the students’ record.
l Comprehensive treatment is emphasised and performed,
but the patients may primarily be serving the teaching goals of
a specialist-dominated student clinic. Treatment may be
completed by clinical instructors or hospital dentists in order
to compensate for the lack of sufficient qualifications of the
students in order to avoid unnecessary suffering from the side
of the patient.
l The treatment planning is primarily based on the perceived
needs as seen from the patients’ perspective and the clinical
teaching process is adjusted accordingly.
Although we will initially comment on the first position, the
aim of the present paper is primarily to discuss the last two
positions (both focusing on comprehensive care) in the light of
what is considered as ‘appropriate knowledge, skills and
attitudes’ attained by the undergraduate student (9, 10).
The patient serving the needs and
requirements of the student
This view complies with traditional curriculum thinking where
the different clinical departments have strong, independent
positions. The students are introduced to and guided through a
segregated and highly specialised clinical setting with teaching
usually based on the prevailing philosophy of authoritarian
professors (4, 5, 8). In this context, patients are supplying the
educational needs defined within each department and
treatment strategies are usually poorly coordinated.
In a historical perspective dental services were driven by
paternalism and the practice of dentistry was based on patients
trusting their dentists. Knowledge and skills developed in this
setting might be quite advanced, but fragmented, rigid and
authority-dominated. Furthermore, the way of ‘using’ the
patients may challenge ethical principles for proper clinical
conduct (11). This teaching regime does not comply with
modern principles of comprehensive care and the development
of critical thinking skills (4, 5, 9, 10) and will therefore not be
further discussed.
The comprehensive, specialist-directed
treatment profile
This approach to clinical teaching is prevalent in modern den-
tal curricula (8–10, 12). An argument for this position is the
demand for professional guidance of an immature student by
an experienced clinician in the treatment planning process.
Clinicians and students are frequently faced with the situation
that the patient does not know the best solution for his/her
oral health problems, demonstrate lack of ability or personal
confidence to decide, want the ‘expert opinion’ as a guiding
advice, have unrealistic or erroneous expectations, have
conflicting values or oppose appropriate treatment suggestions.
Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Patient-centred approach to teaching and learning
All these factors emphasise the importance of intervention from
an experienced and well educated clinician in the clinical teach-
ing process. This attitude complies with the second level ‘The
informative model’ described by Emanuel and Emanuel (8). In
this context Kress (13) and McLauglin (14) went as far as
expressing the ‘the ignorant patient’-concept stating that
consumers should not influence technical medical or dental
decisions. In this context, one should be aware of the opinion
stated by The American Institute of Medicine (4) and Rubin
(5) that comprehensive care is considered an ideal rather than
reality in the education process, and specialist-guided instruc-
tions still focus too heavily on procedures rather than on
patient care.
Treatment needs perceived by the
patient
As mentioned previously the emphasis on cultural competence
is recognised by educators as an important element in the over-
all shaping of minds and attitudes of students and modern
dental practitioners (9, 10). However, this competence is
usually considered of importance for retrieving valid informa-
tion as basis for a professionally conducted, comprehensive
treatment plan rather than creating a sensitive attitude towards
treatment needs as perceived by the patient. A patient-centred
approach acknowledges the autonomy and integrity of the indi-
vidual. In this context the role of the professional will be an
informant and facilitator rather than a tutor/instructor inter-
preted as ‘the interpretitive and the deliberative models’ by
Emanuel and Emanuel (8). However, little is published in
educational literature about a patient-centred approach to
treatment planning. Training modalities to achieve such
competence are described by Schön (7), but outcome measures
are elusive and largely unexplored (1, 5, 6). In the following
some important consequences will therefore be considered and
discussed.
A patient-centred teaching
model – challenges and consequences
In the UK, the General Dental Council has stated in the first of
their key educational principles that dental graduates should be
required to attain the highest standard in terms of knowledge
and understanding, skills including clinical skills, and profes-
sional attributes, in particular recognition of their obligation to
practice in the best interest of patients at all times (9). One
may fully agree on this statement, but the question remains if
it is the patient-centred or the specialist-centred treatment deci-
sion model that represent ‘the best interest of patients’? And
what are the major educational challenges and consequences
related to ‘attain the highest standard in terms of knowledge
and understanding, skills including clinical skills, and profes-
sional attributes’? In the following, some important features
will be discussed related to these statements.
The best interest of patients
Except for orthodontic treatment (15) there is limited informa-
tion in the dental literature about patient preferences and
171
Patient-centred approach to teaching and learning
priorities regarding dental treatment. The ‘illness – sickness –
disease’ model suggested by Hofmann (16) may act as a
conceptual basis for evaluating a patient-centred vs. a special-
ist-dominated treatment model (Fig. 1). The ‘illness’ dimension
reflects what patients perceive as health problems requiring
treatment or cure. The ‘disease’ dimension represents what is
professionally diagnosed as potential or real health problems
eligible for treatment. The ‘illness’ position includes treatment
of subjectively recognised problems while the latter also
includes early treatment of diagnosed conditions that do not
bother the patient or has not, or sometimes will not, develop
into an ‘illness’ (16). The latter position is compatible with a
preventive approach to treatment, but it may also initiate
over-treatment and combined with active practise promotion, a
provider-induced and technology-driven demand might be the
result.
This dichotomy illustrates the difference between an
authoritarian (expert) approach to treatment compared to the
dynamic attitude of a reflective practitioner (7). The concept of
internal vs. external locus of control is of relevance where the
professional represents the external focus while the patient-
centred contains the internal locus of control (17, 18). Accord-
ing to Bandura (18), the latter position is a basic requirement
for lasting behavioural changes.
An essential requirement in any kind of treatment is to
prevent harm to the patient. In a students’ clinic the teacher is
legally responsible for the patients’ well-being (1) and inexperi-
enced students need close supervision in their clinical training.
This does not, however, contradict a patient-centred approach.
In addition, the students should be aware of their limitations
and learn to collaborate with specialists. They should also learn
to use the competence of auxiliary personnel, particularly
dental hygienists, in the best interest of their patients.
Disparities in social factors and oral health between the most
and least advantageous population groups are probably still of
relevance, even in rich countries. This means that dental
students and dentists will meet and treat patients with different
skills, resources and values. With the patient being well
educated in general and particularly in health care questions,
one may expect a growing interest in dental care. The patients
The concept of disease
Illness
Disease Sickness
Fig. 1. Illness is a subjective negative experience that tends to reduce the
capacity of the organism. Disease is a bodily or mental occurrence diag-
nosed by a professional that tends to reduce the capacity of the organ-
ism. Sickness is a social identity assigned to a human being (16). The
inter-relationship between the three different entities is illustrated by the
figure.
172 Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Eriksen et al.
will know more about oral diseases and therefore have higher
demands on dentists and dental students regarding treatment.
Even then the patient may not be aware of any dental disease
and therefore it is important to understand why they should
have dental treatment, and if not treated what potential harm
they might face. This may be even more troublesome to under-
stand if prophylactic treatment is discussed (19). The dental
curriculum must therefore include education of techniques for
learning and improving the ‘therapeutic alliance’ with focus on
understanding and involve the patient in decision making. In
the health care system, a concept known as concordance has
been proposed where both the patient and the professional
share the same views about associated benefits and harm of
treatment (20, 21). A successful interaction between patients,
dentists and dental students depends on a well established and
good communication process. In these processes it is important
to acknowledge and identify the needs of the patient with best
available scientific evidence in conjunction with dental clinical
expertise and ethical principles.
Qualities of the graduate
In the cornerstone paper presenting the profile and competence
for the future European dentist, Plasschaert and co-workers
emphasise the importance of a comprehensive treatment profile
in the dental curriculum (10). However, the major and
supporting competences they present within seven domains
included professionalism, communication and interpersonal
skills, knowledge base, information handling and critical think-
ing, clinical information gathering, diagnosis and treatment
planning, establishment and maintenance of oral health and
health promotion. This might represent a mirage of the quali-
ties of future European dentists more than realistic educational
aims and in their paper (10) little is mentioned about how to
achieve the qualities listed including a discussion of possible
consequences.
Educational challenges
Maupomé and Sheiham (17, 22) demonstrated that senior
students and clinicians frequently comply with a pattern-recogni-
tion treatment model going directly from observation to a treat-
ment plan. A diagnosis invariably and automatically results in a
treatment suggestion (22). This does not comply with the aim ‘to
encourage a questioning, scientific, and self-critical approach to
dental practice’ (9, 10). Consequently, student training in a
patient-centred clinical environment may strengthen the concept
of informed consent and a hypothesis-generating and -testing
attitude in collaboration with the patient.
The wide variation in treatment decisions made by experi-
enced clinicians (23–27) may further question the specialist-
directed approach as a valid and reliable teaching modality. A
patient-centred position may contribute to a more intellectually
challenging and mature educational experience. A development
of the students from novice through competence to reflective
expertise (28, 29) is an important aim that might be facilitated
by a properly guided patient-centred approach.
Randomised, controlled clinical trials (RCT) are considered
as the ‘gold standard’ in clinical medicine and dentistry (30)
Eriksen et al.
Evidence-based dentistry
Scientific
publications
The evidence
Patient
Patient wishes
circumstances
Treatment plan
Fig. 2. An illustration of the three main factors that should be involved
in evidence-based clinical decisions (31).
and the evidence-based attitude is emphasised in guidelines for
a modern dental curriculum (9, 10). However, the RCT-based
guidelines are not equally relevant for every clinical condition.
It is therefore reassuring to read balanced evaluations of the
evidence-based concept including both the scientific evidence,
patient circumstances and wishes in a totality perspective
(31–33) (Fig. 2).
Pedagogic methods have recently been extensively discussed
both in the educational literature and in scientific meetings.
E-learning and problem-based learning are two didactic
methods that have been particularly focused (34) without a
clear evidence for one method being superior to all others.
A ‘blended learning’ strategy may comply with the values
emphasised in a patient-centred approach.
In a patient-centred teaching environment, the clinical
instructors should act as advisors and facilitators. This implies
a re-learning process of traditionally educated dentists in their
role as clinical teachers. This will be important both directly in
the teaching process and indirectly through the instructors’
impact as role models.
Educational arenas
External practice or outreach clinics may be better suited for
implementing a patient-centred clinical education than a
university hospital (3, 35). This should be considered in curric-
ulum planning. Such training is emerging in many dental
schools (35) including the new dental school in Tromsø,
Norway.
Educational consequences
One of the real educational challenges in a proper patient-
centred approach is to include in the undergraduate curriculum
not only a thorough understanding of health, disease and
evidence-based treatment on individual and community levels.
Equally important will be to educate students in how to inter-
pret the signs and symptoms as explained by the patient and to
respect the patient’s values and choices. The core of this philo-
sophy has been expressed by the Danish philosopher Søren
Kierkegaard more than 200 years ago: ‘In order to help a fellow
Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Patient-centred approach to teaching and learning
human being, you do have to understand more than him – but
first of all to understand what he understands. If you don¢t,
your additional comprehension will not benefit him at all’. The
gate to this understanding is an introduction to and appre-
ciation of human sciences such as philosophy, psychology,
sociology and ethics.
A patient-centred teaching model
The focus on patient-centred dental care related to the patient’s
needs and expectations is suggested to be the key attribute of
quality care (36). But dentists do not consistently address
patients’ concerns, and do not always assess the patients’ beliefs
and understanding of their illness. Further, dentists rarely
present treatment options for the patients and the patients also
frequently fail to recall basic elements of their care plan (37).
As a possible way to overcome these discrepancies we have
developed a patient-centred teaching model, which is integrated
in the dental curriculum at the University of Tromsø. To use a
patient-centred approach the dentists need to move beyond the
biomedical view of patients to a biopsychosocial view exploring
the biological, psychological and social components of the
patients’ illness. Therefore, there is a need for reorientation of
scientific and educational perspectives in order to open the way
to a more holistic approach. The theoretical framework of such
a reorientation is presented below.
Mechanisms underlying the
patient-centred teaching model
In understanding the process of change and development, it
is important to distinguish between mechanisms at a
meta-theoretical and an applied level. Dynamic system theory
disclosing the higher meta-theoretical level is a comprehensive
theory of human functioning, and the applied level attempts to
clarify the mechanisms behind clinical decisions and manage-
ment. In our view both levels are necessary in order to under-
stand the underlying learning processes in patient-centred
teaching.
By treating sets of related events collectively it is possible to
recognise similarities across different levels of organisation. In
the dynamic system theory all levels of organisation are linked
to each other in a hierarchical relationship so that change in
one level affects changes in the others (38, 39). All biological
systems belong to a complex system consisting of many indi-
vidual elements of enormous heterogeneity that can interact
non-linearly and non-homogeneously, manifest at all levels of
organisation (38, 40, 41). Furthermore, biological systems are
examples of open systems, which include many components
that are free to relate to one another in a non-linear way. Their
order and complexity are not only maintained over time but
may increase as in the development of a human being (38, 39).
Living systems are also characterised by vortices of energy in
order to maintain continuous metabolic processes of impor-
tance for self-organisation. Therefore developing organisations
are different from the elements that constitute the system and
patterns cannot be predicted solely from the individual
elements (39). In self-organisation the system is attracted to
one preferred configuration out of many possible states, but
173
Patient-centred approach to teaching and learning
behavioural variability is an essential precursor (38–41). The
system theory constitutes therefore an important theoretical
fundament in development and learning in man.
Using a dynamic systems approach, emotions have been pro-
posed to be a part of the same dynamics as perception, action,
cognition, and social behaviour (38). Emotions are described as
relatively stable patterns that are continually construed by com-
plex and dynamic interactive self-organised processes, which are
fluid, context-sensitive, and non-linear. Improved emotional
awareness can therefore be a valuable tool in the education,
which may lead to improved intrapsychical and interpersonal
skills and consequently act as the basis of new self-organisations
resulting in new strategies to handle the patients (41).
Emotional intelligence
Emotional intelligence (EI) is conceptualised in terms of
empathy, perception, appraisal, and expression of emotion,
emotional facilitation of thinking, understanding, analyzing and
employing emotional knowledge and reflective regulation of
emotions (42).
High EI-individuals can better perceive emotions, understand
their meanings and manage emotions better than others (43).
They also require less cognitive effort solving emotional
problems and they tend to be higher on verbal and social
intelligence. Further, they are more effective and they promote
effectivity in others.
Interpersonal skills such as communication, teaching and
working with people with various backgrounds are critical to
academic achievement. High EI-competent teachers and stu-
dents create a safe atmosphere that facilitates to learning (44).
Although there is empirical evidence that EI is crucial in
communication, teaching and working with people (44), few
curricula address the emotional and interpersonal skills that
employers most want in their employees.
Stress and emotions are interdependent i.e. when there is
stress there are also emotions. Stress, emotions and coping
form a conceptual unit with emotion being the superordinate
concept because it includes stress and coping (45). In stressful
clinical situations, the individual may be forced to use stereo-
typical psychological patterns in order to cope with activated
negative affects such as worry, fear and anger. In such situa-
tions there is a risk that the individual becomes involved in
dysfunctional relations that can result in an elevated risk to
develop chronic stress and associated symptoms. A multina-
tional study of dental students has shown that EI is inversely
correlated to perceived stress. Interventions to enhance EI in
dental students have therefore been suggested in order to
increase their stress tolerance (46). Dental students with high
EI cope better with stressors in the dental environment. There-
fore, training in coping mechanisms and skills related to EI is
recommended in order to meet various clinical challenges (46).
Although the environment in the dental clinical education
demands high EI, a training programme for improving the
emotional competence has not been proposed. Reflection and
appraisal, social and interpersonal, and organisation and time
management skills are associated with high EI in dental
students, whereas health-damaging behaviours are associated
with low EI (47, 48).
174 Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Eriksen et al.
A patient-centred vs. a biomedical
model
The biomedical model of disease is derived from the theory
which assumes that diseases are caused only by deviations from
the norm of measurable variables (49). The biomedical para-
digm embraces both reductionism, representing the view that
complex phenomena are derived from a single primary princi-
ple, and mind-body dualism which separates mental processes
from somatic. The biomedical model has not only provided the
norm for the scientific study of diseases, it has also become a
part of our western culture. But the biomedical model is insuf-
ficient, a medical model must also take into account the
patient, the patients’ social context and the society. This
requires a model which derives from a theory which evaluates
all the factors contributing to illness and patienthood rather
than biological factors alone, i.e. the biopsychosocial model.
The biopsychosocial model requires that the dentist accept
the responsibility to evaluate whatever problems the patient
presents. Hence the dentists’ basic professional knowledge and
skills must include social, psychological and biological
competence for decisions and actions.
Historically and still today the biomedical paradigm domi-
nates the dentists’ view of disease while the biopsychosocial
concept seems to be more or less absent in dentistry including
dental education (50). The traditional dental education does
not capture psychological and psychosocial aspects that can be
essential for the diagnostics and treatment planning although
the necessity of a holistic biopsychosocial view of humans and
diseases in dental education have been stressed (51, 52). In
mediating the biopsychosocial model behavioural science play a
central role. This is an interdisciplinary field that concerns the
knowledge and techniques that are applicable to prevention,
diagnosis, treatment and rehabilitation of illness (53).
Conclusions
To be successful in patient-centred teaching, all teachers
involved in the dental education must be educated and trained
in the patient-centred teaching model. Not until the staff has
fully integrated this patient-centred concept will full impact on
the dental education be obtained. To achieve this, the teachers
must be trained to think and act according to the biopsycho-
social model which is the basis of patient-centred teaching.
Thus to educate students and teachers in the biopsychosocial
model is of outmost importance to reach a true patient-centred
teaching model. In order to fulfil the requirement of a patient-
centred teaching model mentioned above we have outlined a
concept that refers to a thoroughly designed dental curriculum
imbued with the system approach that pervades through all the
dental education from the first to the last semester.
References
1 Fugill M. Teaching and learning in dental student clinical practice.
Eur J Dent Educ 2005: 9: 131–136.
2 DePaola D, Slavkin HC. Reforming dental health professions
education: A white paper. J Dent Educ 2004: 68: 1139–1150.
Eriksen et al.
3 Masella RS. The hidden curriculum: value added in dental
education. J Dent Educ 2006: 70: 279–283.
4 Field MJ (ed.). Dental education at the crossroads. Challenges and
change. Washington: National Academy Press, 1995.
5 Rubin RW. Developing cultural competence and social responsibil-
ity in preclinical dental students. J Dent Educ 2004: 68: 460–467.
6 Logan HL, Muller PJ, Edwards Y, Jacobsen J. Using standardized
patients to assess presentation of a dental treatment plan. J Dent
Educ 1999: 63: 729–237.
7 Schön D. The reflective practitioner. How professionals think in
action. NewYork: Basic Books, 1983.
8 Emanuel EJ, Emanuel LL. Four models of the physician-patient
relationship. J Am Med Assoc 1992: 267: 2221–2226.
9 General Dental Council. The first five years. A framework for
undergraduate dental education, 2nd edn. London: General Dental
Council, August 2002.
10 Plasschaert AJM, Holbrook WP, Delap E, Martinez C, Walmsey
AD. Profile and competences for the European dentist. Eur J Dent
Educ 2005: 9: 98–107.
11 Ozar DT. Ethics, access and care. J Dent Educ 2006: 70: 1139–1145.
12 Rohlin M, Svensäter G, Petersson K. The Malmö model: a prob-
lem-based learning curriculum in undergraduate dental education.
Eur J Dent Educ 1998: 2: 103–114.
13 Kress GC. Toward a definition of the appropriateness of dental
treatment. Public Health Rep 1980: 95: 564–571.
14 McLauglin MC. Transmutation into protector of consumer health
services. Am J Public Health 1971: 61: 1996–2004.
15 Espeland LV, Stenvik A. Perception of personal dental appearance
in young adults: relationship between occlution, awareness and
satisfaction. Am J Orthod Dentofac Orthop 1991: 100: 234–241.
16 Hofmann BM, Eriksen HM. The concept of disease: ethical chal-
lenges and relevance to dentistry and dental education. Eur J Dent
Educ 2000: 4: 1–7.
17 Maupomé G, Sheiham A. Explanatory models in the interpretations
of clinical features of dental patients within a university dental
education setting. Eur J Dent Educ 2002: 6: 2–8.
18 Bandura A. Self-efficacy: toward a unifying theory of behavioural
change. Psychol Rev 1977: 84: 191–215.
19 Swenson SL, Buell S, Zettler P, White M, Ruston DC, Bernard L.
Patient-centered communication. Do patients really prefer it?. J Gen
Intern Med 2004: 19: 1069–1079.
20 Elwyn G, Edwards A, Britten N. ‘‘Doing prescribing’’: how might
clinicians work differently for better, safer care. Qual Saf Health
Care 2003: 2: 133–136.
21 Mullen PD. Compliance becomes concordance. Br Med J 1997: 314:
691–692.
22 Maupomé G, Sheiham A. Clinical decision-making in restorative
dentistry. Content-analysis of diagnostic thinking processes and
concurrent concepts used in an educational environment. Eur J
Dent Educ 2000: 4: 143–152.
23 Bader JD, Shugars DA. What do we know about how dentists make
caries-related treatment decisions? Community Dent Oral Epidemi-
ol 1997: 25: 97–103.
24 Bader JD, Shugars DA, Nesbit SP. Comparison of dental schools
and practicing dentists’ restorative treatment recommendations.
J Dent Educ 1995: 59: 419–424.
25 Reit C, Gröndahl H-G. Management of periapical lesions in
endodontically treated teeth. Swed Dent J 1984: 8: 1–7.
26 Kronström M, Palmquist S, Söderfeldt B. Prosthodontic decision
making among general dentists in Sweden. I: the choice
between crown therapy and filling. Int J Prosthodont 1999: 12:
426–431.
27 Kvist T. Endodontic retreatment. Aspects of decision making and
clinical outcome. [Thesis] Swed Dent J 2001 (Suppl. 144).
Eur J Dent Educ 12 (2008) 170–175 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
Patient-centred approach to teaching and learning
28 Crespo KE, Torres JE, Recio ME. Reasoning process characteristics
in the diagnostic skills of beginner, competent and experet dentist.
J Dent Educ 2004: 68: 1235–1244.
29 Dreyfus SE. The five-stage model of adult skill aquisition. Bull Sci
Tech Soc 2004: 24: 177–181.
30 The Cochrane Collaboration. Scales and checklists for randomized
controlled trials: an annotated bibliography. In: Methods Working
Groups News Letter. 1998: 2: 5. http://www.cochrane.org
31 Haynes B, Haines A. Barriers and bridges to evidence based clinical
practice. Brit Med J 1998: 317: 273–276.
32 Guyatt G. Evidence based medicine has come a long way. Brit Med
J 2004: 329: 990–991.
33 Gafni A, Charles C, Whelan T. The physician-patient encounter:the
physician as a perfect agent for the patient versus the informed
treatment decision-making model. Soc Sci Med 1998: 47: 347–354.
34 Association for Dental Education in Europe. Dental graduate educa-
tion in Europe. 31st Annual Meeting, Athens, Greece 2005.
35 Eaton KA, deVries J, Widström E, et al. ‘schools without walls’?’
Developments and challenges in dental outreach teaching – report
of a recent symposium. Eur J Dent Educ 2006: 10: 186–191.
36 Institute of Medicine. Crossing the quality chasm: a new health
system for the 21st century. Washington DC: National Academies
Press, 2001.
37 Campion P, Foulkes J, Neighbour R, Tate P. patient centeredness in
the MRCGP video examination: analysis of large cohort. Brit Med J
2002: 325: 691–692.
38 Thelen E, Smith LB. A dynamic systems approach to the develop-
ment of cognition and action. Cambridge: MIT Press, 1998.
39 Gorowitz S, MacIntyre A. Toward a theory of medical fallibility.
J Med Philos 1976: 1: 51–71.
40 Eriksen HM, Dimitrov V. Ecology of oral health: a complexity
perspective. Eur J Oral health 2004: 32: 239–249.
41 Eriksen HM, Dimitrov V, Rohlin M, Petersson K, Svensäter G. The
oral ecosystem: implications for education. Eur J Dent Educ 2006:
10: 192–196.
42 Goleman D. Emotional intelligence. USA: Random House, 1996.
43 Mayer J, Salovey P, Caruso D. Emotional intelligence: Theory,
findings, and implications. Psychol Inquiry 2004: 15: 197–215.
44 Holt S, Jones S. Emotional intelligence and organizational
performance – implications for performance consultants and
educators. Perform Improve 2005: 44: 15–21.
45 Lazarus R. Stress and emotion. A new synthesis. London: Free
Association Books, 1999.
46 Pau A, Rowland M L, Naidoo S, et al. Emotional intelligence and
perceived stress in dental undergraduates: a multinational survey.
J Dent Educ 2007: 71: 197–204.
47 Pau AKH, Croucher R. Emotional intelligence and perceived stress
in dental undergraduates. J Dent Educ 2003: 67: 1023–1028.
48 Pau AKH, Croucher R, Sohanpal R, Muirhead V, Seymour K.
Emotional intelligence and stress coping in dental undergraduates –
a qualitative study. Br Dent J 2004: 197: 205–209.
49 Engel GL. The need for a new medical model: a challenge for
biomedicine. Science 1977: 196: 129–136.
50 Dworkin SF. The dentist as biobehavioural clinician. J Dent Educ
2001: 65: 1417–1429.
51 Piko BF, Kopp MS. Paradigm shifts in medical and dental educa-
tion: behavioural sciences and behavioural medicine. Eur J Dent
Educ 2004: 8: 25–31.
52 Breivik T, Thrane PS, Murison R, Gjermo P. Emotional stress
effects on immunity, gingivitis and periodontitis. Eur J Oral Sci
1996: 104: 327–334.
53 Schwartz GE, Weiss SM. Yale conference on Behavioral Medicine:
a proposed definition and statement of goals. J Behav Med 1978:
1: 3–12.
175