The effectiveness of a 3D virtual tooth identification test as an assessment tool for a dental anatomy course.

INTRODUCTION: There has been a recent demand in dental education for distance learning and the use of virtual assessment tools that can leverage technology to potentially replace physical testing facilities. However, virtual tools that evaluate student learning should be validated prior to adoption. The aim of this study was to investigate the effectiveness, efficiency and user satisfaction of a 3D tooth identification test for a dental anatomy course that can be given remotely. MATERIALS AND METHODS: First-year dental students (n = 41) enrolled in a dental anatomy course took both traditional in-person practical and virtual 3D tooth identification tests consisting of 25 test items. The test scores, average test durations, faculty time commitment and user perception were collected and analysed. Pearson product-moment correlation coefficients (p < .05) were determined for the criterion measures including real tooth identification test scores, comprehensive written examination and overall grade for the course. RESULTS: The average number of correct answers for the real and 3D virtual tooth identification examination was 21.3 ± 2.65 and 20.7 ± 2.56, respectively. The average test duration for the real and 3D virtual tooth identification test was 25:00 and 21:16 min, respectively. There was a positive correlation (p < .05) of the 3D virtual tooth identification test with the real tooth identification test (0.368), comprehensive written examination (0.334) and the overall course grade (0.646). The total faculty time commitment for the real and 3D virtual tooth identification test was 96 and 65 min, respectively. The students cited difficulty in manipulating the 3D models. CONCLUSION: This study presents evidence that the 3D virtual tooth identification test can be used to assess dental students' understanding of dental anatomy effectively and efficiently.

The Traumatogenic Dynamics of Internalized Stigma of Mental Illness Among Arab American, Muslim, and Refugee Clients.

Understanding the dynamics of mental health stigma through existing frameworks, especially in minorities with higher stigma, is problematic. There is a need to reconceptualize stigma, particularly in highly traumatized groups. The current study examines the validity of a new development-based trauma framework that conceptualizes stigma as a type III chronic trauma that contributes to negative mental health effects. This framework proposes that public stigma is a unique chronic traumatic stress that mediates the effects of similar trauma types in mental health patients. To test this proposition, this study explores the relationships between internalized stigma of mental illness (ISMI), different trauma types, and posttrauma spectrum disorders. ISMI, posttraumatic stress disorder, other posttrauma spectrum disorders, and cumulative trauma measures were administered to a sample of 399 mental health patients that included Arab (82%), Muslim (84%), and refugee (31%), as well as American patients (18%). Age in the sample ranged from 18 to 76 years (M = 39.66, SD = 11.45), with 53.5% males. Hierarchical multiple regression, t tests, and path analyses were conducted. Results indicated that ISMI predicted posttraumatic stress disorder and other posttrauma spectrum disorders after controlling for cumulative trauma. ISMI was associated with other chronic collective identity traumas. While Arab Americans, Muslims, and refugees had higher ISMI scores than other Americans, the elevated chronic trauma levels of these groups were significant predictors of these differences. The results provide evidence to support ISMI traumatology model. Implications of the results for treating victims of ISMI, especially Arab Americans, Muslims and refugees are discussed.

Can peer feedback substitute for faculty feedback in predoctoral dental education?

PURPOSE/OBJECTIVES: The ability to give and receive feedback is a key skill to develop during predoctoral dental education, and the use of peer feedback specifically offers distinct benefits including a different understanding of material due to peers' proximity of knowledge development and assisting with overburdened instructors. However, it is unclear if peer feedback offers similar quality to instructor feedback. METHODS: Dental students in two different graduation years provided quantitative and qualitative peer feedback on a case-based oral and maxillofacial pathology simulation. The data from these exercises were aggregated and analyzed to compare the quality of qualitative feedback to course examination scores. Student perceptions of peer feedback were also recorded. RESULTS: The mean quality of feedback was not correlated with course examination scores, though the number of times students gave high-quality feedback and received high-quality feedback was correlated with course examination scores. Student feedback overall had a lower quality than instructor feedback, though there was no significant difference between instructor feedback quality and the maximum student feedback quality received. Student perceptions of the utility of feedback were positive. CONCLUSION: While instructor feedback is more reliable and consistent, our findings suggest that in most instances, at least one peer in moderate-sized groups is able to approximate the quality of instructor feedback on case-based assignments.

A comparison of virtual reality and three-dimensional multiplanar educational methods for student learning of cone beam computed tomography interpretations.

OBJECTIVES: The purpose of this study was to compare student learning of cone beam computed tomography (CBCT) interpretation using immersive virtual reality (VR) and three-dimensional multiplanar (MP) reconstructions. METHODS: Sixty first-year dental students were randomly allocated to two groups, VR and MP, and underwent a one-on-one educational intervention to identify anatomic structures using CBCT data. All participants completed three multiple-choice questionnaires (MCQs) before (T1), immediately after (T2), and 2 weeks following (T3) the intervention. Additionally, pre-survey, post-survey, NASA Task Load Index (NASA-TLX), and presence questionnaires were completed. Analysis of objective measures of performance on MCQs and subjective data from the questionnaires was completed (α = 0.05). RESULTS: There was a significant increase in test performance and informational recall between T1-T2 and T1-T3 for VR and MP groups (p < 0.001). However, there were no significant differences in performance on MCQs between T2 and T3. Analysis of the Presence questionnaire indicated that the VR group felt decreased distraction (p = 0.013), increased realism (p = 0.035), and increased involvement (p = 0.047) during the educational intervention when compared with the MP group. Analysis of the NASA-TLX indicated that the VR group experienced more physical demand (p < 0.01) but similar cognitive demand when compared with the MP group. Qualitative responses indicated that the VR group had a more dynamic sense of visualization and manipulation compared to the MP group. CONCLUSION: Results from this study show that VR is as effective as traditional MP methods of CBCT interpretation learning. Further benefits of VR educational intervention include increased involvement, realism and less distraction.

American Dental Education Association Compendium Entrustable Professional Activities Workgroup report.

PURPOSE: Entrustable professional activities (EPAs) are discrete clinical tasks that can be evaluated to help define readiness for independent practice in the health professions and are intended to increase trust in the dental graduate. EPAs provide a framework that bridges competencies to clinical practice. This report describes the work of the American Dental Education Association (ADEA) Compendium EPA Workgroup to develop a list of EPAs for dental education and supportive resources, including specifications and a glossary. METHODS: Preliminary work including literature and resource review, mapping of existing competencies, and review of other health professions' EPAs informed the development of our EPAs list. Workgroup members achieved consensus using a modified Delphi process. A Qualtrics survey using a validated rubric for the assessment of EPAs as described in peer-reviewed literature was used. Dental educators, including academic deans, were surveyed for feedback on the content and format of the EPAs. RESULTS: Based on findings in the literature analysis of existing EPAs and competencies in health professions, a list of EPAs was developed along with a description of specifications. The EPA workgroup (nine members from multiple institutions) used the Delphi process in receiving feedback from various experts. A list of 11 core EPAs was vetted by dental educators including academic deans (n = âˆ¼23), and the process of development was reviewed by EPAs experts outside dental education. A glossary was developed to align language. CONCLUSION: These EPAs define the scope of dental practice. This report represents Phase 1 of the EPA framework development and vetting process. Future directions will include a broader vetting of the EPA list, faculty development, and national standardized technology that support this work to optimize implementation.

Oral health educators' reflections on teaching 2022 and beyond.

INTRODUCTION: The global pandemic prompted changes in health science education affecting both teaching and learning. This multi-institutional study assesses the near-term implications of these changes on faculty and faculty development. The project goals were to: (1) describe faculty experiences of teaching during the pandemic; (2) identify ways to sustain new pedagogical approaches, (3) describe the types of support faculty members need, and (4) offer recommendations to enhance oral health professions education. METHODS: A mixed-method approach using exploratory sequential design was conducted in two phases collecting qualitative and quantitative data. Focus group participants included didactic, pre-clinical, and clinical faculty in dental school (DMD/DDS), dental hygiene and dental therapy programs, and also faculty members serving in administrative roles in these programs (N = 37). One hundred forty-four faculty participated in the multi-institutional follow-up survey. RESULTS: Focus group and survey results led to 14 recommendations (nine structural and five individual) for oral health profession institutions and educators. CONCLUSION: Oral health profession education faculty were dramatically impacted by the pandemic and new faculty development needs were identified. Traditional faculty development topics and practices may be no longer applicable in the post-COVID-19 environment. Additionally, the pandemic stimulated creative approaches for curriculum design, teaching, and assessment in oral health profession education. Strategies need to be implemented to sustain these innovations.

Student learning of head and neck anatomy using cone beam computed tomography and immersive virtual reality.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of student learning of anatomy and 3D imaging concepts using cone beam computed tomography (CBCT) and immersive virtual reality (VR) technology. METHODOLOGY: Ninety (n = 90) first year dental students with no previous experience in 3D imaging were recruited. All participants completed a 10-item, multiple-choice questionnaire (MCQ) and a pre-survey prior to the educational intervention. Following a brief video orientation on CBCT and anatomy, each participant underwent a one-on-one educational intervention using immersive VR with calibrated instructors to identify head and neck anatomic structures using a VR/CBCT educational tool. Immediately following the intervention, all participants completed a postsurvey, a second MCQ, NASA task load index and presence questionnaires. Participants completed a third MCQ 2 weeks following the intervention. Analysis of objective measures of performance on MCQ's (p < 0.05) and subjective data from the questionnaires was completed. RESULTS: The students doubled their mean test scores 2.45 ± 1.274 to 5.99 ± 1.576 on MCQ's immediately following the educational intervention (p < 0.05). The significant increase in the MCQ test scores was maintained after 2 weeks, 5.73 ± 1.721 (p < 0.05). There were no gender differences in student test performance. Students rated the immersive VR/CBCT educational intervention experience highly for control, sensory, and realism factors with minimal distraction and frustration factors. CONCLUSION: Results from this study show that immersive VR/CBCT educational intervention improved test performance and contributed to information recall in students. Further benefits reported by participants include the sense of presence and increased engagement using immersive VR.

Developing entrustable professional activities for general dentistry at the University of North Carolina.

INTRODUCTION: As part of curriculum innovation, the University of North Carolina (UNC) Adams School of Dentistry identified core entrustable professional activities (EPAs) that graduates must demonstrate for practice readiness. This paper describes the development of the UNC EPAs and the perceptions of the general dentistry faculty. METHODS: Upon establishing a blueprint of knowledge, skills, and attitudes of UNC graduates, using a distributed leadership approach, faculty teams developed EPAs focused on the patient care process. The American Dental Education Association Compendium of Clinical Competency Assessments and Commission on Dental Accreditation Standards informed the team's work. Perceptions of the assessment framework were examined using a questionnaire completed by 13 general dentistry faculty considering the importance, accuracy, and agreement of each EPA, associated domains of competence, and encounter management on a 6-point rating scale. RESULTS: Distributed leadership was a useful strategy in EPA development to disperse decision-making and build ownership. Through multiple iterations, four EPAs (assessment, plan of care, collaborative care, and provision of care) with associated sub-EPAs emerged. EPAs included a description, required knowledge and skills, and rubrics for assessment. The general dentistry faculty reported a high level of importance, accuracy, and agreement with EPAs, domains of competence, and encounter management. DISCUSSION: EPAs provide a standardized manner to describe the comprehensive work dentists perform, shifting away from individual competencies. The UNC EPAs provide the foundation for longitudinal measures of competence preparing graduates for independent practice. With limited EPAs frameworks available in dentistry, we aim to inform the development and implementation of EPAs across dental education.

A qualitative assessment of dental hygiene educators' COVID-19 related burnout.

PURPOSE: The purpose of this study was to elicit ideas or concerns influencing dental hygiene educators' experiences of personal and professional burnout, burnout working with students, and teaching efficacy in an online/hybrid environment as a result of the COVID-19 pandemic. METHODS: A qualitative, content-analysis study included a convenience sample of dental hygiene educators emails. An invitation to participate in an August 2021 or October 2021 focus group was sent via Qualtricsxm with informed consent, and focus groups were held over Zoom. Conversations were audio recorded, transcribed, and de-identified. Consensus on a codebook by two coders achieved an 88% agreement. RESULTS: Fifty-three were invited to the August 2021 focus groups for a 26% (n = 14) response rate, and 116 were invited to the October 2021 focus groups for an 11% (n = 13) response rate. Contributing factors to experiences of burnout expressed were: (1) work-life balance (n = 59), including (a) overwork, (b) pressure to be available, and (c) lack of boundaries; (2) change (n = 34) involving (a) developing new protocols, (b) constant uncertainty, (c) COVID-19 requirements, and (d) new platforms; and (3) negative interactions (n = 32) with (a) students and (b) faculty. CONCLUSION: A lack of work-life balance from overwork, pressure to be available at all times, no boundaries with students, and an absence of a sense of connection for workplace vitality were contributors to burnout. Work-from-home flexibility, a work environment that supported wellness and mental well-being, and the ability to leave the workplace for periods of time were reported as helpful solutions to combatting burnout.

Impact of Covid-19 on dental hygiene educators: A national survey.

PURPOSE: The purpose of this study was to assess the impact of the Covid-19 pandemic on dental hygiene (DH) educators' perception of personal and professional burnout and efficacy in the online/hybrid learning environment. METHODS: A cross-sectional study of DH faculty members from 327 United States entry level DH programs was invited to participate in this study. A 36 item survey was disseminated in Qualtricsxm March 2021. The Copenhagen Burnout Inventory was used to measure personal, work-related, and burnout related to working with students. The Michigan Nurse Educators Sense of Efficacy for Online Teaching instrument was used to measure efficacy in online/hybrid learning. RESULTS: The survey had an institutional response rate of 46%. Personal burnout scores had a significantly higher mean as compared to work-related and burnout working with students' scores. A majority (66%) of respondents reported often feeling tired. Only personal burnout scores had a significant negative correlation with teaching efficacy scores. Administrators/program directors and full-time faculty had significantly higher mean personal and work-related burnout scores as compared to part-time/adjunct clinical faculty. There were no significant differences in teaching efficacy scores by faculty position and institutional setting. CONCLUSION: COVID-19 had significant impact on full-time DH educators' personal and professional burnout levels. Full-time administrators/program directors/DH educators reported higher levels of personal burnout. It seems that personal burnout has a negative relationship with teaching efficacy. Faculty position rather than institution impacted personal burnout. Despite personal and professional burnout, DH faculty reported low-levels of burnout related to working with students.

Entrustable professional activities framework for assessment of patient handoffs in dentistry.

PURPOSE/OBJECTIVES: The aim of this study is to report data on the lack of a proper patient handoff system in dentistry and dental education and to present a possible solution to integrate this into curriculum using the "entrustable professional activities" (EPAs) framework. METHODS: Delphi participants from seven US dental schools provided feedback on a preliminary definition of handoff, a mnemonic and an assessment rubric. 2019 American Dental Education Association Commission on Change and Innovation in Dental Education (ADEA CCI) participants further evaluated the handoff EPA using the EQual rubric for EPA quality and structure. RESULTS: Delphi participants identified points of transition in dentistry, selected the D-PASS as a mnemonic, and agreed with the evaluation rubric. The ADEA CCI participants agreed the handoff EPA describes work that is essential for the profession and suitable for entrustment. CONCLUSION: The D-PASS rubric is an effective way to assess patient handoffs.

A longitudinal family-level model of Arab Muslim adolescent behavior problems.

Arab-American Muslim adolescents in immigrant families face a number of challenges that put them at risk for behavior problems. This study of Arab-American Muslim Adolescents and their relatively recent immigrant mothers tested a longitudinal family-level model of adolescent behavior problems. Mother-adolescent dyads (N = 530) completed measures of maternal and adolescent stressors, active and avoidance coping, and social support; maternal distress; quality of mother-child relationship; and adolescent behavior problems at Time 1 and approximately 18 months later. The youth were between the ages of 11 and 15 years at Time 1 and 48.7% were girls. Longitudinal analyses were conducted using latent change modeling with change scores from Time 1 and Time 2 data. Social support facilitated active coping for both mothers and adolescents. Although maternal avoidance coping mediated maternal stressors and its effect on maternal distress, maternal stressors and maternal distress were not related to adolescent behavior problems. The only factor mitigating the effects of adolescent stressors on adolescent behavior problems was the quality of the mother-child relationship. These findings suggest that adolescents are insulated from maternal stress and distress as long as there is a good mother-child relationship.

Comparisons of orthodontic residents' performance and attitudes using 2D, 3D, and virtual reality surgical simulation methods.

PURPOSE: Advances in virtual reality technology for surgical simulation methods may improve diagnosis and treatment planning of complex orthognathic surgery cases. The objectives were to assess orthodontic residents' performance and attitudes when treatment planning orthognathic surgery cases using two-dimensional (2D) digital, three-dimensional (3D) digital, and virtual reality (VR) surgical simulations. METHODS: The study had a mixed methods study design involving 20 graduate orthodontic residents. Their previous experiences, confidence, and competence with orthodontic diagnosis and surgical treatment planning were assessed with a baseline survey. Each resident completed 2D, 3D, and VR treatment planning and simulation tasks in a randomized order and recorded their diagnosis, objectives, treatment plan, and special surgical concerns for each case using a treatment planning worksheet. The worksheets were scored and quantitative data were analyzed. Attitudinal responses to the simulation experience were captured with a post-survey and interview. RESULTS: The number of total prescribed surgical movements was greater for 3D and VR simulation methods (p = 0.001). There were no differences in the overall total written treatment plan analysis score among the three surgical simulation tasks. Participants took longer to complete the VR and 3D tasks (p < 0.001) and asked more questions regarding manipulation (p < 0.001) and software features (p < 0.002) for higher fidelity tools. Analysis of qualitative feedback showed positive attitudes toward higher fidelity tools with regard to visualization, manipulation, and enjoyment of the task. CONCLUSIONS: The results demonstrate that simulation methods of increased fidelity (3D and VR) are appropriate alternatives to 2D conventional orthognathic surgical simulation methods when combined with traditional records. Qualitative feedback confirms residents' readiness to adopt VR simulation. However, comprehensive training is needed to increase familiarity and comfort with using the new technology.

Entrustable professional activities framework for assessment in predoctoral dental education, developed using a modified Delphi process.

PURPOSE/OBJECTIVES: The purpose of this study was to define and develop a set of Entrustable Professional Activities (EPAs) for dental education using a modified Delphi consensus approach. EPAs define the core tasks that a graduating dentist needs to perform independently in practice. The EPA framework facilitates assessment of competencies as they manifest in the tasks and independence needed to be ready for practice. METHODS: Feedback was obtained from participants about a list of EPAs, with modifications made after each of the 3 rounds, using a modified Delphi approach. Phase 1 included attendees at the ADEA Fall 2017 meeting (n = 35) who participated in an EPA workshop primarily composed of academic deans. The Phase 2 "reactor panel" consisted of 10 dental schools' academic deans and other individuals with expertise and interest in dental curriculum and assessment (n = 31). Phase 3 participants were attendees at the ADEA CCI 2019 meeting (n = 91) who also participated in a 2-day EPA workshop. RESULTS: In phase 1, overall ratings for acceptability of the EPAs were satisfactory. In phase 2, the next iteration of EPAs was judged as satisfactory for inclusion in curriculum, match well with clinical practice and clarity. In phase 3, the EPAs were judged as satisfactory for being an "entrustable, essential, and important task of the profession." Qualitative feedback suggested wording, measurability, and specific focus of EPA statements is important. CONCLUSIONS: A preliminary set of EPAs was designed for predoctoral dental education through a systematic, careful consensus building approach involving a diverse set of participants.

Using business intelligence and data visualization to understand the characteristics of failed appointments in dental school clinics.

PURPOSE/OBJECTIVES: Broken appointments are an important cause of waste in health care. Patients who fail to attend incur costs to providers, deny trainees learning opportunities, and impact their own health as well as that of other patients who are waiting for care. METHODS: A total of 410,000 appointment records over 3 years were extracted from our electronic health record. We conducted exploratory data analysis and assessed correlations between appointment no-shows and other attributes of the appointment and the patient. The University of Michigan Medical School's Committee on Human Research reviewed the study and deemed that no Institutional Review Board oversight was necessary for this quality improvement project that was, retrospectively, turned into a study with previously de-identified data. RESULTS: The patient's previous attendance record is the single most significant correlation with attendance. We found that patients who said they are "scared" of dental visits were 62% as likely to attend as someone reporting "no problem." Patients over 65 years of age have better attendance rates. There was a positive association between receiving email/text confirmation and attendance. A total of 94.9% of those emailed a reminder and 92.2% of those who were texted attended their appointment. CONCLUSION(S): We were able to identify relationships of several variables to failed and attended appointments that we were previously unknown to us. This knowledge enabled us to implement interventions to support better attendance at Dental Clinics at the University of Michigan, improving patient health, student training, and efficient use of resources.

Adaptation and psychometric evaluation of the Multidimensional Scale of Perceived Social Support for Arab immigrant women.

We adapted the Multidimensional Scale of Perceived Social Support (MSPSS) for use with Arab immigrant women (MSPSS-AW) and estimated the psychometric properties of the adapted version with a sample of 539 Arab immigrant women living in the United States. Confirmatory factor analysis (CFA) supported the proposed three-factor solution. Internal consistency reliability coefficients for the three subscales ranged from good to very good. Additional evidence for construct validity of the MSPSS-AW subscales was demonstrated through relationships with theoretically related measures. We conclude that the MSPSS-AW is reliable and valid for use with Arab immigrant women.

The Multiple Mini Interview as a Dental School Admission Tool: Can It Predict Noncognitive Traits Associated with Professional Behaviors?

The aim of this study was to investigate the reliability and validity of the Multiple Mini Interview (MMI) process and to assess its use as an admission tool to predict noncognitive traits associated with professional behavior during patient care in one cohort of dental students at a single U.S. dental school. Data were analyzed for the 95 candidates who matriculated and graduated as part of the 2017 graduating cohort at the University of Michigan School of Dentistry. All MMI interviewees for one cycle of admissions rotated through ten stations: two traditional interview question stations and eight scenario stations measuring domains that included four questions scored on a five-point Likert scale. Generalizability theory analysis showed the MMI to have good reliability (G Coefficient of 0.74). Station reliabilities (Cronbach's alpha) ranged from 0.88 to 0.92. MMI scores showed a positive significant correlation with students' scores on the Dental Admission Test and Perceptual Ability Test, D1 cumulative GPA, and D4 Patient Management grade. MMI scores positively correlated with professional behaviors relating to three domains-openness, conscientiousness, and emotional stability-thus demonstrating good predictive validity for measuring noncognitive traits associated with professionalism. This study found that the MMI was a reliable and valid tool that predicted key behavioral traits associated with professionalism in dental students.

Adaptation and psychometric evaluation of the multidimensional scale of perceived social support for Arab American adolescents.

The multidimensional scale of perceived social support (MSPSS) was revised for Arab American adolescents (MSPSS-AA). Items measuring social support from significant others were omitted and items measuring support from school personnel were added based on advice from cultural experts. The sample consisted of 635 Arab American young adolescents in metropolitan Detroit. Confirmatory factor analysis (CFA) supported the proposed three-factor solution (family, friends, and school personnel). Internal consistency coefficients for the three subscales of family (alpha = 0.63), friends (alpha = 0.75), school personnel (alpha = 0.72) were good. As predicted, perceived support from family, friends, and school personnel were inversely related to self reports of daily hassles and internalizing behavior and positively related to assistance seeking coping, which provides evidence for construct validity. Support for discriminant validity was also demonstrated with significantly larger correlations between the MSPSS-AA Family subscale and daily hassles specific to parents and the MSPSS-AA Friend subscale and daily hassles specific to peers. These finding suggest that the MSPSS-AA is reliable and valid for use with Arab-American adolescents.

The Patient Management and Professionalism Scale to Assess Dental Students' Behavior in Clinic.

The Ten Item Personality Inventory (TIPI) is a widely used instrument based on a personality framework measuring five dimensions: Extraversion, Agreeableness, Conscientiousness, Emotional Stability, and Openness to Experiences. The aim of this study was to establish a scale to assess dental students' professionalism by adding to the TIPI's five dimensions a set of descriptors that define professional behavior in dental students. The resulting Patient Management and Professionalism Scale (PMPS) was then tested with a cohort of graduating students at the University of Michigan School of Dentistry. To develop the scale, one clinic director and a patient care coordinator from four clinics wrote descriptive statements for each of the five dimensions based on their observations of dental students in the context of their clinical experiences. These descriptors were compiled into a single scale. The PMPS demonstrated good scale reliability and interrater agreement and correlated significantly with students' patient management grade scores and cumulative GPA at the end of their fourth year. Exploratory factor analysis showed the presence of a single factor (professionalism) with all five dimensions loading highly on this factor, accounting for 66% of variance in scores. While a useful standardized measure to assess professionalism in dental students, the PMPS also has a flexible format that makes it easy for other schools to use.