Patient-Centered Communication: Exploring

the Dentist’s Role in the Era of e-Patients

and Health 2.0
Brittany Seymour, DDS, MPH; Helen Yang, BA; Rebekah Getman, MS; Jane Barrow, MS;
Elsbeth Kalenderian, DDS, MPH, PhD
Abstract: In today’s digital era, people are increasingly relying on the Internet—including social media—to access health infor-
mation and inform their health decisions. This article describes an exploratory initiative to better understand and define the role
of dentists in patient education in the context of e-patients and Health 2.0. This initiative consisted of four phases. In Phase I, an
interdisciplinary expert advisory committee was assembled for a roundtable discussion about patients’ health information-seeking
behaviors online. In Phase II, a pilot case study was conducted, with methods and analysis informed by Phase I recommenda-
tions. Phase III consisted of a debriefing conference to outline future areas of research on modernizing health communication
strategies. In Phase IV, the findings and working theories were presented to 75 dental students, who then took a survey regarding
their perspectives with the objective of guiding potential curriculum design for predoctoral courses. The results of the survey
showed that the validity of online content was often secondary to the strength of the network sharing it and that advocacy online
could be more effective if it allowed for emotional connections with peers rather than preserving accuracy of the information.
Students expressed high interest in learning how to harness modern health communications in their clinical care since the role of
the dentist is evolving from giving information to giving personalized guidance against the backdrop of an often contradictory
modern information environment. The authors recommend that the dental profession develop patient-centered health communica-
tion training for predoctoral students and professional development and continuing education for practicing professionals.
Dr. Seymour is Assistant Professor, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine;
Ms. Yang is a Class of 2016 DMD Candidate, Harvard School of Dental Medicine; Ms. Getman is Research Assistant,
Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine; Ms. Barrow is Assistant Dean
for Global and Community Health, Harvard School of Dental Medicine; and Dr. Kalenderian is Associate Professor and
Chair, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine. Direct correspondence to
Dr. Brittany Seymour, Harvard School of Dental Medicine, 188 Longwood Ave., REB 304, Boston, MA 02115; 617-432-1848;
brittany_seymour@hsdm.harvard.edu.
Keywords: dentist-patient relationship, patient-centered care, social media, patient education, dental education, modern health
communication
Submitted for publication 9/7/15; accepted 12/1/15

C
ommunication of health information, de- will ultimately improve individual, community, and
scribed as any information that can aid in public health outcomes.”5
prevention, detection, and treatment of dis- The dental profession has long recognized
ease, is an important component of health care and communication as an important component of the
patient education.1,2 Healthy People 2010 included a practice of dentistry.6-10 In the early 1990s, the
chapter on health communication, including its role American Association of Dental Schools (now the
in disease prevention.3 Considered by researchers American Dental Education Association, ADEA)
to be a vibrant and rapidly evolving field,4 health affirmed communication skills as a core area in
communication is defined as “a multifaceted and behavioral sciences in the dental curriculum.11 In
multidisciplinary field of research, theory, and prac- 2008, the ADEA House of Delegates approved Com-
tice concerned with reaching different populations petencies for the New General Dentist that include
and groups to exchange health-related information, a domain for Communication and Interpersonal
ideas, and methods in order to influence, engage, Skills.12 Furthermore, the Commission on Dental
empower, and support individuals, communities, Accreditation (CODA) defines standards for teach-
health care professionals, patients, policymakers, ing and assessing competencies in communication
organizations, special groups, and the public so that skills for patient education and health promotion.13
they will champion, introduce, adopt, or sustain a Evidence exists that at least some dental schools are
health or social behavior, practice, or policy that teaching health communication in their curricula.9,10

June 2016  ■  Journal of Dental Education 697

 However, a review of North American dental schools information online, as well as the extent to which
published in 2002 reported that only one-third of the it affects consumer health behavior and the patient-
respondents had courses specific to communication doctor relationship.22 Lack of traditional measures
and the courses that did exist tended to be in the form of quality control and misrepresentation of scientific
of lectures and other passive learning or lasted for studies have caused health information on the Inter-
only a day, with limited long-term effectiveness.9 A net to become less predictable or factually reliable.23
recent survey of U.S. dentists by Rozier et al. found Anonymity renders it difficult to assess the legitimacy
that general dentists underutilized communication or veracity of information, and one study reported that
skills, with seven out of ten young dentists in the fictional statements and sites with inaccurate health
study reporting that they received no communication information garnered “high degrees of belief.”24 There
training in dental school.6 While some efforts have is evidence showing that e-patients have refused or
been made to introduce general communication skills terminated recommended dental treatment because
in a standardized manner with specific competen- of health information they found online.25
cies,14-16 there is clearly considerable variation in how In this rapidly evolving health information and
health communication skills are taught and assessed communication environment, the role of dentists
in dental schools. in health communication is likely changing since
While a number of gaps and discrepancies exist dentists today may be only one of many influences
in health communication research and teaching in over patient health decision making. As the dental
dental education,9 we intend to focus on a specific profession continues to recommend use of the Inter-
area of growing interest to patients and practitioners net in health communication and patient education,6
alike: the role of the dentist in an era of “e-patients” we are striving to better understand the impact of
and “Health 2.0.” E-patients, also referred to as In- Health 2.0 on today’s e-patients. This article de-
ternet patients, are actively engaged in their health scribes an exploratory initiative launched to better
care and health decision making processes, value understand and further define the role of dentists in
autonomy and choice, and vigorously perform their modern health communication and patient education.
own health information-gathering, including on the It also includes preliminary findings about student
Internet.17,18 Health 2.0 mirrors the current name of perspectives and provides evidence for informing
the interactive nature of today’s Internet, Web 2.0;19,20 health communication curricula and professional
it is defined as “participatory health care enabled by development moving forward.
information, software, and community” by which
patients can actively collect, create, and share infor-
mation and serve as effective partners in their own Methods
health care.21
Though research on e-patients has been pub- This initiative was determined to not be human
lished in medicine,1,2,17-19,21 less is known regarding subjects research by the Harvard University Faculty
dentistry. When ADEA published its Competencies of Medicine Office of Human Research Administra-
for the New General Dentist, specific language was tion, protocol number IRB15-0816. The exploratory
included about informatics, which could relate to the initiative consisted of four phases. In Phase I, we as-
e-patient. This ADEA document defined informatics sembled an interdisciplinary expert advisory commit-
as “applications associated with information and tee for a roundtable discussion about patients’ health
technology used in health care delivery; the data and information-seeking behaviors online. In Phase II, a
knowledge needed for problem-solving and decision pilot case study was conducted, with methods and
making and the administration and management of analysis informed by the roundtable and advisory
information and technology in support of patient committee recommendations from the first phase.
care, education, and research.”12 Rozier et al. also Phase III consisted of a debriefing conference to
discussed the use of technology in their study, incor- outline future areas for further research on modern-
porating “patient-friendly practice” as a communica- izing health communication strategies. In Phase IV,
tion technique, which included referring patients to we presented findings and working theories to a
the Internet for health information.6 total of 75 predoctoral students to gain a preliminary
Because the Internet is an open communica- student perspective and to guide us in potential cur-
tion platform, health care practitioners have raised riculum planning for dental school and professional
concerns over the quality and accuracy of health development courses.

698 Journal of Dental Education  ■  Volume 80, Number 6

Phase I: Advisory Committee
Table 1. Abbreviated version of case used in Phase I of
Roundtable project
Case-based teaching has been shown to be an Of the 291 diseases and conditions measured by
engaging and effective approach for discussion.26 the Global Burden of Disease 2010 study, untreated
dental caries (cavities) was found to be the most
Thus, to launch the roundtable event, we wrote a brief prevalent disease worldwide. In fact, over the past 20
case based on an actual scientific article circulating years, untreated cavities have risen by 38.1% globally.
online at the time. A shortened version of the case is Water fluoridation is a widely recognized, highly cost-
effective method for preventing dental caries. This well-
shown in Table 1; the longer version has since been researched intervention was recognized to be among
published with more detail in a separate article.27 the top 10 greatest public health achievements of the
20th century. Yet, despite its success, water fluoridation
Invitations to join the advisory committee and has not gained universal support. For example, a recent
participate in the roundtable discussion were sent via journal article with recognized limitations was released
email to 35 researchers and scholars from a variety naming fluoride as one of six newly identified develop-
mental neurotoxicants. The authors’ conclusions were
of fields across Harvard University. The two-hour based on a single previous meta-analysis by the same
event, which took place in May 2014, included an authors, and the validity of the authors’ methods and
introduction to the case and major questions to be their conclusions were questioned by experts.
Yet, only hours after the article’s publication,
discussed, including questions about e-patients, the story of fluoride as a new threat to normal child
Health 2.0, implications for policymakers and health development was covered online by CNN, USA Today,
practitioners, and related issues. Open discussion Forbes, and Time, among other popular media outlets.
These four popular news sources alone generated over
ensued. The advisory committee attendees provided 54,000 views and shares through social media within
insights and guidance for developing a pilot study 24 hours. Anti-fluoride sentiments have since echoed
across social networking and video-sharing sites.
from the case. Communities across the United States are petitioning
Audiorecording with written permission from to abolish water fluoridation, and some are advocating
attendees was made and transcribed for internal for elimination of fluoride use altogether, no matter the
kind or source.
use and to inform the design of a formal pilot study How is it possible that so much confusion and
building from the written case. The transcript was controversy exist surrounding one of public health’s
reviewed by three research team members separately. greatest achievements and most effective prevention
measures at a time when dental caries is on the rise
This was not a formal qualitative study but a prelimi- worldwide?
nary internal process to guide the early stages of the
initiative and to inform the design of future research.
Findings and conclusions were cross-compared, with
The purpose of the four-hour conference, which took
the conclusions and major theories mutually agreed
place in September 2014, was to review theories and
upon by the research team and then presented back
outcomes from the previous roundtable, debrief on
to advisory committee members for respondent
findings from the pilot study testing those theories,
validation.
and determine further areas for scaled research and
related activities, including teaching and curriculum
Phase II: Pilot Study development.
Outcomes of the roundtable and oversight from The conference consisted of a large-group
the advisory committee informed the design, imple- discussion and three small-group breakout sessions.
mentation, and analysis of a pilot case study based Themes of the breakout sessions were determined
on the fluoridation case we wrote. The purpose of the in real time by the committee based on interest and
pilot study was, on a preliminary basis, to test theories suggestions from the large group. The large group
and hypotheses that resulted from the roundtable came back together after the breakout sessions to
discussion. Detailed methods and results of that study share outcomes and conclusions. Preliminary next
have been published in a separate article.22 steps were outlined by the large group.

Phase III: Debriefing Conference Phase IV: Student Perceptions

Invitations for a follow-up conference were Preliminary theories, results from the pilot
sent to an expanded advisory committee, which study, and early conclusions were presented to 75
included the existing 21 members plus seven new predoctoral dental students on three occasions. The
members who became interested in the initiative. first was an invited presentation for approximately

June 2016  ■  Journal of Dental Education 699

 30 students during a “Hot Topic” session at the 2015 decisions and behaviors by individuals who are en-
American Student Dental Association (ASDA) An- gaging with this information?”28
nual Session. A standard ASDA survey was admin- Attendees initially suggested that this challenge
istered to students following the session. Attendees is a problem of information: we must get more and
were asked to rate the quality of the speaker and better information out to more people. However,
presentation using the standard rating scale survey the diversity of the group added a wide variety of
administered after all presentations at the conference. perspectives, and over the two hours, the sentiment
Students rated from 1 (low score) to 5 (high score) the began to shift. Conclusions from the event included
speaker, content, overall session, and if they would the possibility that, due to the social nature of Internet
like to see this presentation again in the future. platforms, online networks may function as a way
The next session was held at the Harvard to connect and make a statement about users rather
School of Dental Medicine (HSDM) for interested than to merely deliver information. The Internet and
students unable to attend the ASDA meeting. This communication sciences experts present agreed that
session took place as part of the HSDM Office of challenges with communicating online have less to do
Global and Community Health Seminar Series, with the content and more to do with connecting and
and approximately ten dental students from all four ascribing to particular social identities and norms.
years attended. The third session was held during The general consensus was that the problem is not
the spring 2015 HSDM DMD leadership course for merely how to create and disseminate better health
approximately 35 third-year students. Surveys were information to more people, but also how to predict
administered after both sessions, on which students the sociological interactions of people within and
were asked to rate the following topics from 1 (low between online networks, as well as their subsequent
score) to 5 (high score): how interested in modern reactions to that information offline.
health communication are you, how important do you
think modern health communication is for the dental Phase II: Pilot Study
profession, how influential do you think modern me-
After iterative deliberation with advisory com-
dia are on patient health decision making behaviors,
mittee members, we designed and implemented a
should HSDM include teaching on modern media and
small pilot study to explore the prospects of four
health communication practices, and how much do
primary theories about health communication and the
you think modern media and today’s Internet culture
Internet: 1) peers may be more likely to successfully
will impact you as a dental professional?
share health messages online than outside experts or
authorities; 2) the Internet is a place for conversation
and content creation rather than for information con-
Results sumption only; 3) today’s Internet is predominantly
social, with information content secondary to the
Phase I: Advisory Committee values of the networks sharing it; and 4) advocacy
Roundtable that allows for emotional connections with others is
likely to be more successful online than the preser-
Of the 35 researchers and scholars invited, 21
vation of information accuracy. Overall, the results
attendees from ten schools and centers from within
suggested that these working theories were valid and
Harvard University convened for the roundtable
worthy of further investigation.22
event, jointly sponsored by the Harvard Global
Health Institute and the Nieman Foundation for
Journalism at Harvard University. This highly in- Phase III: Debriefing Conference
terdisciplinary group consisted of leaders from the Four months after the initial roundtable, a
fields of medicine, dentistry, public and global health, follow-up debriefing conference was held, sponsored
education, policy, communication science, media and by the Harvard Global Health Institute and Harvard’s
the Internet, health decision science, and journalism. Nieman Foundation for Journalism, Berkman Center
The overarching question addressed at the meeting for Internet and Society, and Shorenstein Center on
was the following, as framed by the Harvard Global Media, Politics, and Public Policy, as well as the Har-
Health Institute: “If today’s technology ensures vard School of Dental Medicine. Attendees were 25
unprecedented access to information, why don’t we professionals, including original advisory committee
see a stronger corresponding improvement in health members and additional invitees, such as writers for

700 Journal of Dental Education  ■  Volume 80, Number 6

the New York Times and Boston Globe who attended ASDA meeting and two at HSDM). On the standard
not to report on the event but rather to contribute to ASDA survey administered to students following the
the discussion. “Hot Topic” session, all questions were unanimously
The small-group breakout sessions tackled given a score of 5 out of 5. The HSDM survey had
questions defined by the Harvard Global Health an overall 83% response rate among students who
Institute such as “How do we incentivize trust on- attended either of the two HSDM sessions. Similar
line?,” “As journalists, where is the line between to the ASDA session, those students expressed strong
‘click bait’ and substantive content?,” and “How beliefs that modern media and the Internet influence
might health providers, policymakers, and media patients’ health behaviors, and the students expressed
experts collaborate more effectively to move accurate strong interest in learning more about how to provide
health information from reliable sources out across patient-centered communications in response to
the network?”29 In summary, the groups agreed that Internet information and misinformation (Figure 1).
these questions demand interdisciplinary approaches
in order to optimize the health outcomes of individual
patients and populations. Discussion
Outcomes from the four phases of this initia-
Phase IV: Student Perceptions tive cannot be considered generalizable since our
Students were highly engaged in active dis- approach was intended to be exploratory in nature
cussion during all of their three sessions (one at the due to the highly novel focus of this work for den-
Aggregated Mean Score

Figure 1. Aggregated mean scores on surveys administered to Harvard dental students (N=33)
Note: Responses were given on a scale ranging from 1=lowest to 5=highest. Questions were as follows:
A. How interested in modern health communication are you?
B. How important do you think modern health communication is for the dental profession?
C. How influential do you think modern media are on patient health decision making behaviors?
D. Should HSDM include teaching on modern media and health communication practices?
E. How much do you think modern media and today’s Internet culture will impact you as a dental professional?

June 2016  ■  Journal of Dental Education 701

 tistry. In addition, this study consisted of input from than on facts and accurate science.34 This inclination
self-selected individuals and professionals already could explain why, for example, even though the
interested in and, in some cases, quite knowledge- science around fluoridation is sound, the Internet is
able about Internet and modern health communica- teeming with controversy over the topic that is often
tion challenges and opportunities. In spite of these tied to tightly knit social networks and their norms.22
limitations, our findings provide insights into future The social nature of the Internet allows e-patients to
opportunities for more robust research and subse- contribute to dialogue, share, and create additional
quent curriculum development in order to optimally information—an inherent value of social platforms.36
prepare prospective and practicing dentists for the In this Health 2.0 environment, information flows in
era of e-patients and Health 2.0. Patients today are multiple directions among many people and sources
moving away from having unquestioning trust in their and is no longer guaranteed to be accurate, often
providers to being proactive partners throughout the blurring the lines among opinion, anecdote, and
entirety of the patient-provider interaction, stemming evidence.37
largely from the copious amounts of information Health communication is moving from an
available to them online.7 emphasis on health education toward behavioral and
Internet usage in the U.S. is ubiquitous and social change.38 While the health professions have
widely relied upon to network, communicate, historically placed importance on health communi-
search and share information, and entertain.30 Social cation training and education, they have nonetheless
media sites such as Facebook, Twitter, YouTube, been slow to adopt advances in information technol-
Tumblr, and WordPress have hundreds of millions ogy relative to other fields.21 This delay is largely
of visitors daily and are considered by many to be because there have been very few, if any, intervention
trusted sources of information.31 In 2013, one study studies on effective education strategies in dental
reported that 90% of adult Internet users in the U.S. schools.10 Even as dental educators have begun to
had searched for health information online, with recognize the value of social media in enhancing
24% doing so once a week or more.32 Also in 2013, dental education,39-41 researchers are only beginning
a systematic review of the literature summarized to investigate the impact of online information and
that 39% of adults had turned to social media, such Health 2.0 on the choices and attitudes of e-patients.42
as Facebook, for health information.33 The Internet, The current unknowns about the social nature
including social media, has been described as having of the Internet today and its use as a tool for health
the potential to improve health communications and communication help to explain the gaps in dental
positively influence health behaviors.18,31,33 These school curricula. Increasing dentists’ comfort level
technologies democratize access to health infor- in discussing Internet health information with their
mation, educate the general public, and facilitate patients could have a significant positive impact on
dialogue among patients, doctors, and the public.31 the physician-patient relationship.43 Additionally,
They can facilitate spread of helpful information that Laurence et al. found that dental students’ apprecia-
would otherwise be difficult to understand or access.33 tion for the value of health communication improved
Given the universality and ease of Internet use, it is with adequate education and training.8 Our survey
appropriate that dentists use the web as a source of results aligned with these prior findings.
health information for their patients.6
However, simply encouraging our patients to
search the Internet is likely not enough to optimize Conclusion
their health outcomes. Results from our exploration
in this study of the challenges and opportunities the The diversity and breadth of interest our work
Internet provides to improve and modernize health on this topic has garnered are impressive and reflect
communication suggest that we must also better the novelty and significance of the concepts. Addi-
understand how patients use it from a sociological tionally, the outcomes from our exploratory initia-
perspective. Connecting and belonging are innate tive are backed by existing sociological theories,
human characteristics, which likely drive people to strengthening the potential for future research. The
use social media platforms online.34,35 These quali- rising ethos of autonomy and hyperpersonalized
ties influence information-seeking behavior; in fact, health information-seeking behavior by e-patients
they potentially lead people to make decisions based and Health 2.0 has dissolved many traditional long-
more on identity construction and preservation rather standing approaches to patient education. The role

702 Journal of Dental Education  ■  Volume 80, Number 6

of the dentist appears to be evolving from one of 8. Laurence B, Bertera E, Feimster T, et al. Adaptation of
providing information to one of guidance to person- the communication skills attitude scale (CSAS) to dental
students. J Dent Educ 2012;76(12):1629-38.
alize and corroborate patients’ findings and resulting
9. Yoshida T, Milgrom P, Coldwell S. How do U.S. and Ca-
decisions as they navigate the often confusing and nadian dental schools teach interpersonal communication
contradictory modern information environment. With skills? J Dent Educ 2002;66(11):1281-8.
patient-centered health communication becoming an 10. Hannah A, Millichamp J, Ayers K. A communication skills
emerging expectation in today’s culture, it is more course for undergraduate dental students. J Dent Educ
2004;68(9):970-7.
important than ever that the dental profession devel-
11. American Association of Dental Schools [now American
ops patient-centered health communication training Dental Education Association]. Curriculum guidelines for
for predoctoral students and provide professional behavioral science. J Dent Educ 1993;57(8):648-57.
development and continuing education for practic- 12. American Dental Education Association. ADEA compe-
ing professionals. We hope our exploratory initiative tencies for the new general dentist. J Dent Educ 2015;79(7):
can serve as a springboard for action, encouraging 813-6.
13. Commission on Dental Accreditation. Accreditation stan-
the dental profession to capitalize on pioneering op- dards for dental education programs. At: www.ada.org/~/
portunities to advance health communication for our media/CODA/Files/predoc.ashx. Accessed 7 Sept. 2015.
patients and communities through research, educa- 14. Kalenderian E, Skoulas A, Timothe P, Friedland B. Inte-
tion, and intervention. grating leadership into a practice management curriculum
for dental students. J Dent Educ 2010;74(5):464-71.
15. Kalenderian E, Taichman RS, Skoulas A, et al. Developing
Acknowledgments the next generation of leaders in oral health. J Dent Educ
We wish to acknowledge our event sponsors 2013;77(11):1508-14.
at Harvard—the Harvard Global Health Institute, 16. Skoulas A, Kalenderian E. Leadership training for post-
doctoral dental students. J Dent Educ 2012;76(9):1156-66.
Nieman Foundation for Journalism, Berkman Center
17. Meehan TP. Transforming patient to partner: the e-patient
for Internet and Society, and Shorenstein Center on movement is a call to action. Conn Med 2014;78(3):175-6.
Media, Politics, and Public Policy—and our advisory 18. Masters K, Ng’ambi D, Todd G. “I found it on the Inter-
committee members for making this publication pos- net.” Sultan Gaboos Univ Med J 2010;10(2):169-79.
sible. We also wish to acknowledge Harvard School 19. Scanfeld A, Scanfeld V, Larson E. Dissemination of health
of Dental Medicine’s Department of Oral Health information through social networks: Twitter and antibiot-
ics. Am J Infect Control 2010;38(3):182-8.
Policy and Office of Global and Community Health 20. Eytan T. The Health 2.0 definition: not just the latest, the
for their support of this initiative. Finally, we wish greatest! 2008. At: www.tedeytan.com/2008/06/13/1089.
to thank Social Driver for consultation and expertise. Accessed 4 Nov. 2015.
21. Hawn C. Take two aspirin and tweet me in the morning:
how Twitter, Facebook, and other social media are reshap-
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704 Journal of Dental Education  ■  Volume 80, Number 6