Traditional dental education

Traditional dental education is an apprenticeship model and mainly discipline-based. In the early days of dental education, perhaps this model had worked well. But today, it has led to a ‘bloated curriculum’ and predisposed students to mechanical approaches to learning and clinical decisions. Discipline-based curriculum offers no help in drawing the line between what is necessary to know and what is merely ‘nice’ to know. It is not true that greater didactic knowledge or practice reflect a higher level of learning.

In assessing learning outcomes, better performance means having the ability to perform in a wider range of circumstances and to respond appropriately to the situation. The traditional dental curriculum cannot produce this consistently.

Novice to expert

If we look at the novice to expert curve, there is no difference between the beginner, the competent performer or expert if we only look at the end product (i.e. the technical aspect). The significant difference lies in the steps taken, use of feedback, definition of task and adaptation to environmental conditions prior to reaching the end-point. The process of moving from novice to competence is therefore a journey of independence.

Education is a path—not a destination and not the accumulation of nuggets of knowledge or a repertoire of skills. Curriculum design, for too long, has focused on what should be learned and not who is responsible for that learning. A competency-based education assumes that learning to become a professional is a progression through stages and competency represents the point along this path where the learner understands the foundations of his/her skills and has internalised appropriate professional values to work independently in normal settings and manage his/her own continued growth. The definition of a competent graduate should be one who will be able to combine the appropriate supporting knowledge and professional attitudes and perform skills reliably without assistance.

Competency-based curriculum

Each stage of development from novice to competence requires different educational strategies:

1. Novices need structure, clarity of goals, single, and clearly explained approaches.
2. The experience for producing competence is different:
   • the structure must be withdrawn systematically;
   • students should be given opportunities for applications where multiple approaches exist;
   • students should be able to evaluate their own work; and
   • students should be able to articulate reasons for their decisions.

In the field of dentistry, those involved in curriculum review and implementation should bear in mind that competencies are skills essential for beginning the practice of general dentistry and not specialist practices. Competencies combine the appropriate supporting knowledge and professional attitudes, both of which are performed reliably without assistance.

The first step in a competency-based curriculum is the development of a set of competency statements to define what knowledge, skills and attitudes the new dental graduate should possess. This set of competency statements will then provide a standard for identifying the core content of the curriculum and allowing the assessment of outcomes of the curriculum. Competencies in the curriculum should be reviewed and modified to be responsive and reflective of the educational needs of the students, disease patterns, community demands and changes in clinical practices.

At the outset, other learning experiences should be differentiated from core competencies. These are desirable clinical and behavioural knowledge, skills and attitudes that students should experience, learn or be exposed to without the expectation of reaching competency. To avoid bloating the core curriculum, these ‘nice-to know’ elements can be included as enrichment modules or electives.

Organisation of competency statements

Domains: Domains represent the broad categories of professional activities and concerns that occur in the general practice of dentistry. The concept of domains is to encourage an eventual structure and process in the undergraduate curriculum that is more interdisciplinary and less sectional.

Major competencies: Major competencies within each domain are identified as relating to that domain’s activity or concern. A major competency is the ability to perform or provide a particular, but complex, task or service (e.g. ‘the new dentist must be able to perform an examination that collects biological and psychosocial information needed to evaluate the medical and oral condition for patients of all ages’). The complexity of this service suggests that multiple and more specific abilities are required to support the performance of this major competency.

Supporting competencies: Supporting competencies are more specific abilities and could be considered as sub-divisions of a major competency. The achievement of a major competency requires the acquisition and demonstration of all supporting competencies related to that particular service or task (e.g. ‘the ability to identify the chief complaint’ is a supporting competency). While less complex than a major competency, a supporting competency requires more specific abilities that are termed foundation abilities.

Foundation abilities: Foundation ability is the product of didactic and laboratory instruction that imparts information and experiences that are pre-requisite for satisfactory attainment of supporting competencies. Foundation ability encompasses knowledge, skill and attitudes.

Foundation knowledge is the ability to use information and correctly answer specific questions (e.g. in an examination). Foundation skills are the ability to follow rules in specific situations to produce acceptable results in a standardised situation (e.g. an operative procedure on a typodont). Foundation attitudes are positive intellectual and behavioural actions (e.g. treatment planning according to patients’ needs and not the student’s need).

The inclusion of any foundation ability in the curriculum should be based on its direct support of one or more of the major and supporting competencies.

Conclusion

The competency-based curriculum was implemented in 1997. In 2001, we saw the first batch of students who had undergone the competency-based curriculum graduate. It is still a bit too early to comment on the learning outcomes but some significant observations were made during the last four years. The learning environment has changed from an apprenticeship model and passive learning to one that integrates learning strategies with outcomes. With competency outcomes as our guide, the curriculum is more dynamic. Staff are more reflective and many reviewed and changed their teaching strategies. With these positive changes, we hope that the dental school will produce graduates who will be better prepared to face the challenges of the future.

References

1. Dreyfus, H.L. & Dreyfus, S.E. (1986). Mind over Machine. New York: The Free Press.
2. Benner P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. New York: Addison-Wesley.
3. Commission on Dental Accreditation Standards for Dental Education Programs. (1986). Chicago: American Dental Association.
4. Snow, R.E. (1989). ‘Toward Assessment of Cognitive and Conative Structures in Learning’. Educ Researcher 18:8–14.
5. Chambers D.W., Ed M. (1993). ‘Toward a Competency-based Curriculum’. J Dent Educ 57:790–793.