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DISCOVERY! |
Department of Dental Care Administration, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115; alexiab9{at}attbi.com
KEY WORDS: evidence-based medicine • clinical trials • evidence-based education
As we studied to become health-care professionals, we were students in the formal sense. We have since come to recognize that learning does not stop after we receive our diplomas and degrees, but is a life-long venture. We have the privilege of taking care of people, and with that privilege comes responsibility. We have a responsibility to ourselves, our patients, and our students to use, in the best ways possible, the ever-expanding base of knowledge available to us.
As I take a moment to reflect on my scientific career, I am struck by the wealth of knowledge, experience, and creative minds with whom I have collaborated as my career has evolved. My first and most important mentor was my father, Dr. Francis Antczak, who was, to me, the true essence of someone who took care of the whole person by taking care of his or her oral health. At the University of Connecticut School of Dental Medicine, I received a stellar basic science education, since medical and dental students attended classes together, dissected cadavers together, and all were required to pass Part I of the National Medical Boards before we embarked on separate paths for our clinical training. This combined basic science education made both the MD and DMD students realize that as dentists we are physicians of the oral cavity, and that the mouth is the gateway to the rest of the body. As a dental student, I had the good fortune to study with Dr. Howard Bailit, who advised me to obtain a degree in public health after I completed my dental education. However, before embarking on more academic studies, I seized the chance to spend some time in Europe. While a dental student, I studied with Dr. Kenneth Kornman, who taught me clinical periodontics as well as the microbiological basis of oral diseases. Because of this training with Dr. Kornman, after graduating from UCONN I was able to work with Dr. Niklaus P. Lang in Bern, Switzerland, creating an anaerobic microbiology laboratory: I grew anaerobes in the Alps! During that year, I was exposed to dental education and practice in a culture different from the one in which I had grown up and studied. We took plaque samples from schoolchildren’s teeth to culture the bacteria and, subsequently, followed the children to see which teeth became carious. Although identifying the bacteria that resided in the schoolchildren’s teeth was the work I performed, living and working in a different environment were the highlights of the experience.
Once I began my post-doctoral education, I was able to study and then work with pioneers and leaders in health services research while obtaining my training in public health. When I returned from Switzerland, I enrolled at the Harvard School of Public Health (HSPH) as a Kellogg Fellow and studied for my Master’s in Public Health (MPH). With encouragement from my Master’s advisor, Dr. William Stason, I continued in school and obtained my Master’s of Science (MS), and Doctorate of Science (ScD) degrees in Health Policy and Management. For my doctorate in Public Health, Dr. Milton Weinstein was my thesis advisor. When I found out several years later that I was his first doctoral student, I realized that we were both, at different levels, new to our shared endeavor. That recognition led to an understanding and appreciation that have inspired me throughout my life. As professor and student, doctor and patient, and in countless other relationships, we teach each other and develop dynamic partnerships of exploring and learning. Each one is new and each challenge unique, no matter how many times we may believe that a new experience resembles an old one. It is the nature of an effective, life-long learner to keep his or her mind off "auto pilot"—to take delight in exploring, probing, and challenging, and to learn to consider new possibilities as we build our ever-expanding base of knowledge and understanding.
My doctoral thesis was a cost-effectiveness analysis of periodontal disease control (Antczak-Bouckoms and Weinstein, 1987). While working on my dissertation, I began teaching a course in dental public health and advised Master’s students. I also gave birth to my first child on Labor Day weekend that year. When I defended my dissertation that June, I dedicated it "To Sarah, who slept through the night". Later, I worked with Dr. J.F.C. Tulloch, a Robert Wood Johnson visiting scholar from the University of North Carolina. We performed a decision analysis evaluating the extraction of asymptomatic impacted third molars (Tulloch et al., 1987; Tulloch and Antczak-Bouckoms, 1987). At Harvard I also studied and worked with Drs. Harvey Fineberg, Frederick Mosteller, Howard Frazier, Chester Douglass, and Thomas C. Chalmers. Dr. Howard Raiffa at the Harvard Business School advised me to study clinical problems that were common and not unduly complicated.
Through Dr. Chalmers, I was introduced to critical ideas about research design, systematic reviews, and evidence based health care. He was a visiting professor at HSPH when I met him. When he learned that I was a dentist, his response was, "Ah, dentistry...there are no randomized controlled trials in dentistry!" This, of course, was not true. As it happened, I was working on my doctoral thesis, trying to figure out how to make sense of all the split-mouth clinical trials comparing surgical with non-surgical treatment of periodontal disease. How fortuitous it was that I should connect with the Godfather of clinical trial methodology: the Clinical Trial Police Sergeant, Dr. Thomas C. Chalmers. That chance meeting with Tom Chalmers led me to several choice adventures, including many a summer holiday "On Golden Pond". Tom Chalmers’ get-away was his family home, which the movie industry rented to film the movie which featured Jane Fonda, Henry Fonda, and Katherine Hepburn. Tom would gather colleagues and their families there for weekends of sailing, waterskiing, and wine-tasting. Being the true scientist, he would add a touch of scientific evaluation to our weekends on "the Pond". In addition to wonderful food, plenty of exercise, and the best in intellectual jousting, he organized "blind" wine tastings. This activity of tasting and scoring wines in a blinded fashion served several purposes. It managed to break down any barriers that may have existed between students and faculty, between levels of faculty status, or between scientists and friends. It was a marvelous equalizer and a most enjoyable way to bring people together. (Gradually, we were achieving the ultimate team goal: to make the whole greater than the sum of its parts.) It was also a tribute to the fact that Tom Chalmers lived by what he professed: "Above all else, randomize and blind." For him, that was the only way to determine the truth. These informal gatherings gave young scientists the forum to initiate discussions of possible research questions to pursue that they may have felt uncomfortable initiating in more formal academic settings. He gave us confidence, a sound investigational discipline, and an intellectual springboard for testing and learning.
In a similar manner, Dr. Frederick Mosteller has held breakfast meetings at the Harvard Faculty Club each month for several years. Students and faculty meet to present research projects ranging from nascent ideas to the implications of final study results. Again, these meetings are attended by a diverse group of students, faculty, and researchers who are willing to gather in Boston at 7:45 a.m. for coffee, bagels, and the finest in intellectual exchange. Another Chalmers has been instrumental to my career. Dr. Iain Chalmers from Oxford, England, was one of the founders of the Cochrane Collaboration, an international network of practitioners, researchers, and patients, who prepare and maintain systematic reviews of evidence on the effects of health care based on results of randomized controlled trials (RCTs) and other studies when RCTs are likely to be impossible. Although not related to each other, Thomas and Iain Chalmers shared a passion that has advanced our learning and expanded our understanding as researchers to seek more effective ways of helping people by taking account of research evidence derived from unbiased studies. It was through Thomas Chalmers that I met Iain Chalmers and began working to amass RCTs in oral health for the Cochrane Oral Health Group (Antczak-Bouckoms and Shaw, 1994).
My experiences with Thomas and Iain Chalmers helped to form the foundation for the topic to which I would now like to turn: evidence-based health care and its future. Evidence-based (E-B) medicine has been developing over the past 30 years (Evidence-based Medicine, 1992) and has been defined as follows: "Evidence-based medicine is the practice of making medical decisions through the judicious identification, evaluation, and application of the most relevant information" (Friedland et al., 1998). Although many people have joined the E-B Health Care Bandwagon, I believe that it is now time to take this movement a step farther and begin to think in terms of evidence-based education for physicians, dentists, nurses, and other health professionals.
Evidence-based education proposes that what we know in health care is based on a "shifting sands" foundation. Although there are some things which we know with greater certainty than other things, most of what we know is based on a constantly changing foundation as new information and understanding are acquired. As students are developing their professional knowledge base, it is important for them to recognize that what they are learning must be constantly updated. New information is being acquired at a rapid pace, and our understanding of diseases and optimum treatments is in a perpetual state of flux. The response "but this is what I learned in school" is no longer adequate. Health-care professionals must recognize that, because of the fantastic advances in our understanding of biological systems and the expectation that we will assimilate information at ever-increasing rates, what is taught in school is "knowledge in development". What evidence-based education proposes is that, as information is imparted to students in school, it should be accompanied by codes to identify the confidence in our understanding about the diseases and relevant treatments. For example, for something for which we have the utmost certainty, the information would be assigned a Gold Star. For something with a lesser degree of conviction, a Silver Star; with little solid evidence, a Green Star; and so on, according to the strength of the evidence. As new information is acquired, the star status might change. This would allow students to develop a knowledge base that is continuously evolving. As students become comfortable with the idea that new information will change their knowledge base, a new type of professional will begin to transform health care. These professionals will not be afraid to question what they are doing or what is best to do for the patients whom they treat. Providers of health care will seek evidence to inform their care-giving decisions, underscoring the reality that even the most seasoned health-care professionals will always be students. Evidence-based education fosters a commitment to life-long learning and develops open and active minds, reminding us that we continue to be students in the best sense. There is always something else to learn, so let us keep investigating.
I personally have had some things to learn in the last few years that may provide an unusual addendum to the story of my career development. On February 25, 1996, while driving home from an indoor soccer game with my family, our car was struck by a falling tree in a fierce windstorm. My husband and six-year-old son, sitting in the back seat, were killed instantly. I was knocked into a coma from which I did not awaken for six weeks. When I did finally regain consciousness, I learned of their deaths and found that I had now joined the disabled community, since the tree had shattered my ninth thoracic vertebrae, resulting in a complete spinal cord injury. It has taken me several years to begin dealing with the aftermath of the hand that life has dealt me. First, I was in what I refer to as the Human Doing Stage, where I did things just to prove that I could. For example, I woke up early in the morning before my two remaining children to make them breakfast before they went off to school. Next, I was in the Human Becoming Stage, where I did more creative, adaptive things like learning how to drive a handicap-adapted car, and I managed to have my dental license re-instated and a dental hand-piece made with a button rather than a foot pedal to press to operate the rheostat so that I could treat patients again. The final phase is the Human Being Stage, where I am again a human being with all the feelings and emotions that go along with that. I do not believe that I need to have my spinal cord injury repaired so that I can walk again in order to be a human being. I simply need to be healed sufficiently to go out into the world and be something besides the freak who survived that terrible accident. As you can see, I have learned many lessons lately, and I intend to keep on learning, since I am sure that there will be many more challenges and more joys to come. And as you have read, I have had a wealth of people nurturing my education thus far. I would like to take this opportunity to thank them and the many others whom I am sure I have failed to mention. I certainly cannot disappoint everyone by letting their guidance and teachings be wasted.
Received April 14, 2003; Accepted May 13, 2003
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REFERENCES |
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 TOP REFERENCES |
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Antczak-Bouckoms AA, Weinstein MC (1987). Cost-effectiveness analysis of periodontal disease control. J Dent Res 66:1639–1635.
Evidence-based medicine (1992). A new approach to teaching the practice of medicine. Evidence-Based Medicine Working Group. J Am Med Assoc 268:2420–2425.
Friedland DJ, Go AS, Ben Davoren J, Shlipak MG, Bent SW, Subak LL, et al. (1998). Evidence-based medicine. A framework for clinical practice. Stamford, CT: Appleton and Lange.
Tulloch JFC, Antczak-Bouckoms AA (1987). Decision analysis in the evaluation of clinical strategies for the management of mandibular third molars. J Dent Educ 51:652–660.[Abstract]
Tulloch JFC, Antczak AA, Wilkes J (1987). The application of decision analysis to evaluate the need for extraction of asymptomatic third molars. J Oral Maxillofac Surg 45:855–863.[ISI][Medline]
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