gms | German Medical Science

Conventional methods of dental education have typically utilized didactic, discipline-based curricula to teach students those skills and professional values in a subject centred matter [1], [2]. The effectiveness of those conventional methods has been questioned in order to equip graduates with a wide range of dental competencies [3].

Dental curricula have to be focused on desired learning outcomes and core competencies expected at graduation due to the fact that the dentist’s role changes from a highly skilled technician toward an oral health care physician [2].

The IOM (Institute of Medicine) report [4] recommended to implement rather a generalist role model than a specialist role model, to teach a patient-centred education rather than a student-centred education and to assure continuity of patient care rather than segmented patient care.

As a dental course approach of posing contextualized questions that are based upon "real life" clinical problems, case-based learning (CBL) is used to stimulate and underpin the acquisition of knowledge, skills, and attitudes via clinical cases [5], [6]. The curriculum, which was evaluated in this study, is a patient-oriented, CBL-based study course. It is based on several columns: comprehensive biomedical basics, completely integrated and interdisciplinary preclinical training, medical clinical knowledge and skills, and finally comprehensive dental clinical abilities and skills and special knowledge in fields of prognostic expectation. The curriculum is developed as a holistic concept, which includes all dental disciplines of restorative dentistry as there are operative and preventive dentistry, periodontology, prosthodontics, special dental care and paediatric dentistry. Individual treatment steps are carried out by students on the basis of self-responsibility due to competence acquired in the different disciplines. Disease specific competences, knowledge and familiarity are addressed in combined theoretical and practical modules and repeatedly trained. Comprehensive patient care and primary health care approaches are the main principles of the clinical CBL courses.

One outcome widely used to assess the effectiveness of a dental curriculum it is to measure self-perception of graduates regarding their competences and obtain their opinions about strengths and weaknesses of a curriculum and the importance of its various components [3], [7], [8], [9], [10], [11], [12], [13], [14].

However, whereas there are studies in medical education [15], no study has yet described the self-perceived relevance of key competencies in dental education for fulfilment of day-to-day work, how well these competencies are taught and how well dental school education prepared for job requirements. We hypothesized that CBL curricula stimulate independent learning and demonstrate equivalent or superior preparation of key competencies compared to the requirements in professional life.

The primary research question of our study was to assess nine key competencies required at their day-to-day work by graduates from CBL-based curriculum. Secondly we assessed how well those competencies were taught in CBL-based curriculum and whether these competencies as taught in CBL-based curriculum sufficiently cover the day-to-day work requirements of dental graduates.

407 graduates from a patient-oriented, case-based learning (CBL) dental curriculum (Witten/Herdecke University, Germany) who graduated between 1990 and 2006 were eligible for the standardized survey according to the independent Centre of Higher Education Development (CHE, Germany) [15], [16].

The survey was conducted between 2007 and 2008; due to missing mailing addresses in the graduate’s almanac we contacted 404 dental graduates by postal service and e-mail. The set return percentage of questionnaires was achieved with a reminder method of two mails and four e-mail deliveries in a fixed time schedule. An anonymized ID-code for each graduate prevented multiple survey responses. Allocation concealment was ensured by data safety instructors (Career Service, UW/H) in accordance with German law (BDSG §5). All participants in the study participated voluntarily (BDSG §4a) and provided informed consent.

The standardized questionnaire consisted of 38 items [15], [16]. The questionnaire contained baseline demographic data and professional status. Furthermore, nine competencies were assessed as required in current employment by the questionnaire and whether these were adequately represented in the respective curriculum (original phrase: “Please evaluate to which extent the following competencies are (A) required in your day-to-day job and (B) were taught in CBL-based curriculum”). The following nine competencies as published in the study protocol of the independent Centre of Higher Education Development (CHE, Germany) [16] were included as outcome measures in the present study in order to enable comparability: “Independent learning/working”, “Practical dental skills”, “Psycho-social competence”, “Teamwork”, “Problem-solving skills”, “Dental medical knowledge”, “Interdisciplinary thinking”, “Business competence”, and “Research competence”. These outcome variables, which were evaluated by graduates, were collected using a 6-point Likert scale on which a score of one (1) reflects the positive end ("very intensively required/taught"), and a score of six (6) the negative end ("not at all required/taught") of the scale.

Baseline demographics and clinical characteristics are presented as mean ± standard deviation (SD) for continuous variables and percentage (frequency) for categorical variables.

To determine whether dental education sufficiently covers the job requirements of dentists, the mean difference (∆) between the ratings of competencies as required in day-to-day work and as taught in medical school was calculated by subtracting those from each other. This comparison demonstrated whether an education was perceived to cover job requirements. It also permitted detection of deficits (negative mean difference [∆]) and surplus (positive mean difference [∆]) of teaching in the different CBL curriculum for each competency. Spearman’s rank correlation coefficient was calculated to reveal statistical significance. A p-value<0.05 was considered to indicate statistical significance.

Statistical application software (PASW Statistics (SPSS), version 18.0.0., IBM Cooperation, Somers, NY 10589, USA) was used for all statistical analyses.

Correct completed and responded questionnaires of 168 graduates formed the study sample. The response rate of 41.6% was achieved.

The percentage of male and female graduates participating in the investigation was almost equal (male: 51.8% vs. female: 48.2%) whereas distribution after study termination yielded slightly more data about younger state examination age groups (1990-1998: 40.1% vs. 1998 – 2006: 59.9%) (see Table 1 [Tab. 1]). A homogeneous distribution quantity of the graduate groups concerning gender, age at graduation and date of survey (average age 34.73 years), duration of study, current labour condition, completion of medical research thesis and professional experience was achieved (see Table 1 [Tab. 1]).

The most required competencies at their day-to-day work according to the Likert scale were “Practical dental skills” (1.84±1.46.), “Independent learning/working” (2.01±1.37), “Business competence” (2.27±1.57) and “Psycho-social competence“ (2.32±1.38) (see Table 2 [Tab. 2]). In contrast, graduates required less competencies like “Team work” (2.50±1.53), “Interdisciplinary thinking” (2.76±1.32) and “Research competence” (4.40±1.42) at their day-to-day work (see Table 2 [Tab. 2]).

Graduates deemed that the CBL curriculum facilitated preparation in “Practical dental skills” (1.59±0.67), “Independent learning/working” (1.89±0.88) and “Dental medical knowledge” (1.98±0.83) (see Table 2 [Tab. 2]). In contrast, preparation in “Psycho-social competence“ (2.93 ±1.23), “Research competence” (3.72±1.28) and “Business competence” (5.10±1.07) were rated poorly in CBL curriculum (see Table 2 [Tab. 2]).

This investigation underlines that in intensively taught competencies like "Practical dental skills" (∆+0.21, p<0.001) and "Dental medical knowledge" (∆+0.42, p<0.001) the qualifications surpassed the demands of professional life, and that graduates developed a pronounced surplus of competencies there. Even in the less positively rated field of "Research competence" they still felt trained sufficiently for the demands of professional life (∆+0.60, p<0.001) (see Figure 1 [Fig. 1]).

“Psycho-social competence” (∆-0.66, NS) and “Problem-solving skills” (∆-0.07, p<0.001) were not taught enough and graduates rated these as competency deficits (see Figure 1 [Fig. 1]). “Business competence” was highly required in professional life, but poorly taught in dental school (∆-2.86, p<0.001).

CBL graduates stated that they were trained superior in six out of nine competencies according to the requirements of profession (statistical significances: p<0.001; Spearman’s rho>0). The education met the requirements in “Problem-solving skills” (p<0.001; Spearman’s rho>0). “Psycho-social competence” (NS) and “Business competence” (p<0.001; Spearman’s rho<0) were not taught to the level needed in professional life (see Figure 1 [Fig. 1]).

Competencies such as “Practical dental skills” and “Independent learning/working” are related to high clinical value and mirror classic CBL strengths [17], [18].

Interestingly, dental graduates rate “Independent learning/working” as a non-medical competency to be more required than other dental medical competencies. This is in agreement with the CBL and PBL theory of preparing graduates for long-life learning and open-ended exploration of issues [17], [19].

In contrast to PBL graduates CBL graduates evaluate “Research competence” as less required in day-to-day work [15]. It seems that CBL graduates are not compensating dental medical knowledge by independently acquiring research information [17], [20], because they rate “Dental medical knowledge” as more required than “Research competence”.

The importance of the addressed topic is supported by the publication Cowpe et al. [21]: The paper presents the “Profile and competences for graduating European dentist”, published primarily 2005 [22] and updated 2009 [21]. Whereas the competencies evaluated in the present study are based on criteria applied for research concerning education in general medicine the educational goals suggested by Cowpe at al. are specified for the concerns of dental education and are, therefore, even more relevant for the definition of educational goals in dentistry [21]: professionalism (I) including “Problem-solving skills”, “Teamwork” and “Business competence”; interpersonal, communication and social skills (II) including “Psycho-social competence”; knowledge base, information and information literacy (III) including “Dental medical knowledge”, “Research competence” and “Independent learning/working “; clinical information gathering including “Dental medical knowledge” and “Practical dental skills” (IV); diagnosis and treatment planning including “Practical dental skills” and “Interdisciplinary thinking” (V); therapy: establishing and maintaining oral health (VI) and Prevention and Health Promotion (VII) including “Practical dental skills”.

CBL-based graduates in particular rate “Practical dental skills” as being much better taught at dental school compared to studies concerning conventional curricula [23]. This result may be affected by demands of extensive practical parts in a repeating order after acquiring the theoretical background in CBL manner. In conjunction with previous studies among dental graduates our results underline strengthens and shortcomings of a CBL curriculum described in the literature [3], [7], [8], [9], [10], [13].

“Independent learning/working” ratings confirm the strength of CBL-based curriculum in teaching the complexity of cases in various disciplines such as cognitive and executive competencies. In this curriculum students are called for responsibility concerning individual treatment planning and practical dental care for their patients, which may lead to an improved “Independent learning/working” competence. These findings may also support the hypothesis that CBL methods directly and indirectly improve dental medical skills by improving independent learning [20], [24], [25], [26].

Research competence may be a weakness of CBL-based curriculum. The evaluated curriculum is patient-centred, which may possibly neglect advanced laboratory courses or lessons in good clinical practice. Our findings in conjunction with a review by Colliver et al. about PBL-based curricula [27] have a distinct disadvantage in losing the ties between educational theory and research [27].

Our data suggests that the CBL-based curriculum fulfilled all job requirements except for three out of nine competencies (see Figure 1 [Fig. 1]) and moreover, the CBL-based provided a significant educational surplus in six competencies (p<0.001), especially in “Dental medical knowledge” and “Research competence”.

In seven out of nine competencies Spearman’s rank correlation coefficient is positive (0.115<Spearman’s rho<0.323) and reveals a slight tendency for equally rating the importance of the evaluated competency both in education as well as in the daily work after graduation.

Our results further demonstrate that “Business competence” is insufficiently taught in the evaluated CBL-based curriculum. Spearman’s rank correlation coefficient is negative (Spearman’s rho=-0.315) and indicates a slight tendency of contrary ratings concerning teaching of this competence and requirement in day-to-day work. Thus, it may be of great interest to incorporate aspects of business administration and management which apparently are demanded by the clinical job [3], [7], [8], [28].

In addition, “Psycho-social competence” is not sufficiently taught by the CBL-curriculum and needs further improvement to meet job requirements [7], [8].

The results need to be evaluated in the context of our study limitations. The response rate was adequate [11]. Graduates were chosen from only one dental school (Witten/Herdecke University, Germany), and there may be differences with respect to realization of the CBL framework in other studies which may limit external comparability of the observed findings. However, we considered the different methodological approaches comparing different educational forms such as CBL, PBL or conventional methods. But due to the above mentioned specific methodological approach the results of the present study may only be scientifically conferred to other CBL-based curricula. However, the results might still be helpful as a research based contribution in the discussion for future curricular development in dentistry as suggested in the goals published by Cowpe et al. [21].

The described assessments of competencies were based on self-perception [7], [14]. Some studies suggest that self-perception can differ from objective measures [29], [30], but Schlett et al. suggest very similar data to objective measurements concerning self-perception of graduates [15]. Given the limitations of the present analysis, further research to confirm and extend our findings such as longitudinal follow-up studies and objective assessments of competencies is mandatory.

This survey among dental graduates demonstrates that the CBL-based curriculum is associated with a strong positive effect on almost all key competencies, which are highly required in the job of dentists. However, psycho-social and business competences deserve closer attention in future CBL curricular development.

We thank Mrs Kerstin Gardeik from the Career Service Witten/Herdecke, Germany for her outstanding support.

The authors declare that they have no competing interests.