|Year : 2015 | Volume
| Issue : 2 | Page : 230-236
Need for paradigm shift in Indian dental education: A case for change toward competency-based education
Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Belgaum, Karnataka, India
|Date of Submission||13-Dec-2014|
|Date of Acceptance||14-Oct-2015|
|Date of Web Publication||21-Nov-2015|
Department of Oral Medicine and Radiology, KLE Vishwanath Katti Institute of Dental Sciences, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dental education came into existence in the early 20 th century in India and is at a critical juncture at present. Dental education, as we know it today, evolved from the Gies Report in 1926, i.e., university-housed and scientifically based shortly after Flexner made his landmark report on the existing and proposed medical education system. Present-day education system is exam driven. This is compounded by compartmentalized approach to patient management as the present curriculum is not designed for either horizontal or vertical integration. Although graduates perform exceedingly well in the academic environment, it has been observed that they are not ready for practice. Many dental schools in the west are gradually undergoing a paradigm shift and transitioning to a competency-based education curriculum. Schools must become unburdened from departmental courses and move toward interdisciplinary integration. This paper highlights the need for shift in paradigm of dental education in the Indian context.
Keywords: Competency-based education, dental education, reforms in dental education
|How to cite this article:|
Lagali-Jirge V. Need for paradigm shift in Indian dental education: A case for change toward competency-based education. J Indian Acad Oral Med Radiol 2015;27:230-6
|How to cite this URL:|
Lagali-Jirge V. Need for paradigm shift in Indian dental education: A case for change toward competency-based education. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Jul 19];27:230-6. Available from: http://www.jiaomr.in/text.asp?2015/27/2/230/170143
| Introduction|| |
Dental education came into existence in the early 20 th century in India and is at a critical juncture at present. Dental education, as we know it today, evolved from the Gies Report in 1926, i.e., university-housed and scientifically based  shortly after Flexner made his landmark report on the existing and proposed medical education system.  Ultimately, the goal of Gies evaluation of dental education was to elevate dentistry to the rank of a medical specialty, to become an independent partner in the health care system. Despite the required course work and high test scores, new graduates generally do not understand human biology because basic science is not made practically relevant to them. The significance of learning basic sciences is not understood by the learners. What is learned in the classroom is not always reinforced in the dental clinic for oral tissues or medical problems. Exposure to medical problems is clearly not serving the purpose as students are not able to integrate this experience in handling medically compromised patients in dental clinics.
The present-day education system is exam driven. Content of instruction is driven by assessment. This is compounded by compartmentalized approach to patient management as the present curriculum is not designed for either horizontal or vertical integration. Although graduates perform exceedingly well in the academic environment, it has been observed that they are not ready for practice. They are not able to apply theory in practice. Many graduates have to work as an "apprentice" during or after internship with dental practitioners to understand and acquire patient and practice management skills.  The quality of health care services is dependent on the quality of health care education. In addition to this, assessment practices are flawed. To correctly determine a student's learning, the assessment should be appropriate for the learning outcome and method of instruction.
Interest in competencies and measuring specific learning is accelerating throughout the world.  Many dental schools in the west are gradually undergoing a paradigm shift and transitioning to a competency-based education (CBE) curriculum. , Schools must be released from departmental courses, a fixed 4-year time course, technical requirements, and classical lecture formats; i.e., schools must move from a teacher-centered curriculum to a student-centered one. To accomplish this change, dental school faculty members need to become educational professionals, learning how to educate adults for a professional career. 
| What is CBE?|| |
The Oxford dictionary defines competence as the ability to do something successfully or efficiently.  Competence (or competency) is the ability of an individual to perform a job properly. CBE emerged in the United States in the 1960s after the Russians launched Sputnik in 1957. The Americans prided in being technologically advanced and wanted to be the first to go into space. However, the launch of Sputnik put a huge dent in their pride. This led to major overhaul in the education system as the Americans felt that the very foundation upon which American technological superiority rested was on its education system. The first official step in this process occurred in 1958 when the United States Congress passed the National Defense Education Act.  This was followed by transformation of the education system from the lowest rung and upward.
In health professions education, "competency" means the behavior expected of beginning independent practitioners. This behavior incorporates understanding, skills, and values in an integrated response to the full range of circumstances encountered in general professional practice.  CBE focuses on outcomes of learning. CBE addresses what the learners are expected to do rather than on what they are expected to learn about.
| Rationale for Change|| |
Bruce J. Baum suggested that dental schools should aim to produce a graduate who:
Such a graduate will be able to function in a health care system in which oral health truly is integrated with total health. 
- Is a lifelong learner, capable of being able to grow and adapt as change occurs in our science base and health care systems;
- Has a sense of community responsibility;
- Is technically competent at dental surgical procedures;
- Is competent at managing oral medical (stomatological) disorders; and
- Is competent treating ambulatory, medically compromised individuals.
In novices, information is compartmentalized; therefore, they apply knowledge to solve problems by trial and error to integrate bits of pre-existing knowledge. Hence, knowledge presented to students should be structured and sequenced, so that they are ready to perform on the job.  Thus, an education system is required that stimulates critical thinking, self-directed learning, integration among disciplines, and competency-based curriculum. Dentists are expected to contribute to the achievement of the general health of patients by implementing and promoting appropriate oral health management. A dentist must have acquired this ability through the achievement of a set of generic and subject-specific competencies - abilities which are essential to begin independent, unsupervised dental practice. Entry-level and exit-level competencies have to be defined for undergraduate and graduate dental education, which the student must demonstrate before graduating. 
To achieve this, the competency statement must include clinical skills and lay emphasis on acquiring managerial skills as well. All these competencies should be achieved by the time he or she obtains the first professional degree. Reforms in dental education in India are an ongoing debate. Hence, the time is suitable to bring the winds of change. Kadagad et al. in their paper have explained how Indian dental education can also be restructured on the lines of the Profile and Competencies for the graduating Dentist (PCD) in the European Union.  In the process of restructuring, we can implement competency-based dental education in India and move toward global convergence of dental education. ,
[TAG:2]Components of CBE  [/TAG:2]
In order to introduce CBE, Hendricson and Smith have described three questions:
Knowledge, skills, and values the student must possess at the time of graduation, so that he/she is ready for the next level (PG/practice)
- What knowledge, skills, and values must the student possess at the time of graduation, so that he/she is ready for the next level (PG/practice)?
- What learning experience will enable the student to acquire these competencies?
- What proof or evidence is needed to establish that the student has attained these competencies?
The first question requires us to identify the expected outcomes.
What learning experience will enable the student to acquire these competencies?
Three models of competency-based curricula have been described in literature: Top down planning, readiness model, and horizontal curriculum structure. The top down planning is a need-based approach in which the needs of the community drive the curriculum and learning. The readiness model moves away from the traditional calendar-based system; in this system, no fixed time is allotted to attain competencies. The students remain in training until he/she demonstrates the skills required for patient care without assistance. The horizontal curriculum incorporates integration across disciplines. 
The present curriculum revolves around calendar-based and quota-based deadlines. The system of requirement chasing fosters an environment in which learners give priority to their needs and then to patient needs. So, there is a possibility that students coax patients into undergoing procedures because they need to show it in their records, and the patient probably does not require it. This is in opposition to the basic tenets of professionalism and ethics. Therefore, if we are to evolve as professionals, we need a curriculum that enables learners to go beyond chasing requirement (or quota).
We have a discipline-based approach - meaning each discipline has a well-structured syllabus, but if we look at the daily timetable, there is no link between the classes. For example, the regular timetable in the first year consists of lectures in anatomy, biochemistry, and physiology on any given day. The syllabus for each subject is well organized, but between the disciplines, there is very little connection. Horizontal and/or vertical integration of disciplines would make the learning experience more fruitful.
Proof or evidence required to establish attainment of these competencies - assessment
A major challenge in implementing competency-based curriculum is assessment. Assessment has been defined by standards for educational and psychological testing as "Any systematic method of obtaining information from tests or other sources, used to draw inferences about characteristics of people, objects, or programs."  Instruction (learning) drives assessment and vice-versa. Instruction and assessment are inseparable and dependent on each other. Both should fit like lock and key. Only the right key (assessment method) will unlock the learning outcome. The main method of assessment of students has been by written tests (constructed response tests and selected response tests) and by observation for the laboratory/clinical/preclinical assessments. Both are seen as highly subjective unless a structured rubric is employed to score performance in any type of assessment. For clinical skills, the observed assessments focus on the end product.
The routine of "requirement chasing" or "quota chasing" to complete a specified number of repetitions of clinical procedures has been criticized. This is a cause of great anxiety to students and their performance and behavior are driven by availability of patients.  To assess learning outcome, we need to stop assessing competency based on quota and assess the quality of work done. The purpose of observed assessment is to rate performance of activities that cannot be assessed by written assessments. Observed assessment can be made formative and summative. Formative assessment occurs during regular clinical work on a daily basis and can be used for feedback and in the final internal assessment. Summative assessment is the final exam where there is no scope for feedback.
To do justice to CBE, assessments have to be structured. Miller's pyramid of learning [Figure 1] has been used to design assessment methods in health professions education.  The different levels of learning require different methods of assessment. To minimize bias and make student assessment fair and impartial, assessments have to be structured and objective. Rubrics are supposed to support student self-reflection and self-assessment, as well as communication between an assessor and those being assessed. In this new sense, a rubric is a set of criteria and standards typically linked to learning objectives. It is used to assess or communicate about performance or process tasks. O'Donnell et al. have outlined the procedure for development of rubrics in dental education.  The oral diagnosis department at University of Pittsburg, USA has developed a rubric to grade students in the 3 rd and 4 th year for daily clinical evaluation. Students are aware of the content of this rubric. Faculty members complete the assessment on a daily basis. At the end of 4 th year, the total grades are summed up to give the final score for each student. Students are considered competent in oral diagnosis if they score in the honors level. This rubric covers recording case histories, examination, diagnosis, prescribing radiographs, treatment planning, follow-up, making and interpreting radiographs, documentation, and professionalism. Kramer et al. have described various assessment methods for dental students. This Dental Student Assessment Toolbox was created to assist dental educators with the critical, yet challenging task of determining the optimal methods for assessing students' progression toward and ultimate attainment of the competencies designated as necessary for the entry-level practice of general dentistry. ,
|Figure 1: Miller's pyramid of learning with corresponding assessment methods|
Click here to view
| CBE in Oral Medicine and Radiology|| |
Competency statements describe the knowledge, skills, attitudes, and values that a dental graduate must have, i.e., the requisite competence to enter into the safe, independent practice of dentistry.  Competence statements are a dynamic document that should be periodically revised based on feedback from the outcomes of student assessment and program evaluation. Competency documents are organized in different formats, and usually have an introductory rationale and explanation. Some are a sequential listing of statements without groupings. The most common approach, however, is to identify first broad groupings, general categories, or "domains." Within these domains are "major" competencies and "supporting" competencies. Major competencies are an integration of basic biomedical, clinical, and behavioral sciences, and are therefore broad and multidisciplinary in nature. Supporting competencies are more specific in their description, particularly in terms of foundation knowledge and skills. Some such documents provide only a framework based on which individual institutions develop their own set of competency documents as in the US and Canada, while the European Union document is more elaborate and has defined six broad clinical competencies with supporting competencies. The Dental Council of India (DCI) has described a syllabus for BDS course with objectives and competencies under knowledge, skills, and attitudes which are broad and open to interpretation. We require specific competency statements, learning outcomes, and an overhaul in the curriculum - instruction, assessment, and content of instruction. 
The Association for Dental Education in Europe (ADEE) has prepared a document with competency statements for the graduating dentist. This document was prepared to promote convergence of standards of dental education in Europe. This report titled Profile and Competencies for the Graduating European Dentist (PCD) - update 2009  has defined seven domains which are:
The competencies to be achieved under these are categorized as:
- Interpersonal, communication, and social skills.
- Knowledge base, information and information literacy.
- Clinical information gathering.
- Diagnosis and treatment planning.
- Therapy: Establishing and maintaining oral health.
- Prevention and health promotion.
Be competent at: A dentist should on graduation demonstrate a sound theoretical knowledge and understanding of the subject, together with an adequate clinical experience to be able to resolve clinical problems encountered independently or without assistance.
Have knowledge of: A dentist should on graduation demonstrate a sound theoretical knowledge and understanding of the subject, but needs/has only a limited clinical/practical experience.
Be familiar with: A dentist should on graduation demonstrate a basic understanding of the subject, but need not have clinical experience or be expected to carry out procedures independently.
During the process of preparing a document, we also require a glossary of terms to prevent confusion. For example "examination," "evaluation," and "assessment" have been used to determine the learning outcomes. However, examination is more appropriate for patient examination, evaluation for determining the outcome of a program, and assessment is more suitable to describe the learning outcome.
It is important to note that these are the competencies to be achieved in all the disciplines of undergraduate dental education and are not confined to one particular department. Professionalism has been given priority in this list, as being a dentist is not only about giving good treatment or getting good grades. It is about the human touch. It is about the behavior expected of a professional. To achieve competencies in each of the seven domains, it is evident that the curriculum requires horizontal and vertical integration of disciplines. Similarly, the American Dental Education Association (ADEA) has also framed competencies for the new general dentist in which competencies have been classified under the following domains. 
Dental schools in these regions follow the respective guidelines. A search of electronic literature for competency statements in Oral Medicine did not turn up with useful results for undergraduate training in Oral Medicine. Competencies for specialty training in Oral Medicine have been defined by the General Dental Council in the UK,  Australia,  and many more countries. Based on the recommendations made in the 5 th World Workshop in Oral Medicine, Oral Medicine curriculum was made one of the areas for discussion in the subsequent meeting.  During the 6 th World Workshop in Oral Medicine in the year 2014, a survey on international consensus for the validation of clinical competencies for specialist training was presented. This survey had been conducted in more than 30 countries. The details of this survey will shortly be published in the OOO journal.  However, the International Association of Dental and Maxillofacial Radiology (IADMFR) has defined competencies for dental undergraduates in dental radiology. 
- Critical thinking.
- Communication and interpersonal skills.
- Health promotion.
- Practice management and informatics.
- Patient care.
- Assessment, diagnosis, and treatment planning.
- Establishment and maintenance of oral health.
Each statement has been outlined as follows:
1.1. Major competency
1.1.1. Supporting competency
188.8.131.52. Foundation ability
The major domains identified by IADMFR are:
Under each of these domains are the major competencies, supporting competency and foundation ability. Domains are the broad categories of activities. Major competencies under each domain relate to the domain's activity or concern. Major competency is the ability to perform or provide a particular but complex task. Supporting competencies are more specific abilities and are subdivisions of a major competency. To achieve a major competency, all supporting competencies have to be mastered. Foundation ability is the result of didactic and laboratory instructions which impart information and experiences that are pre-requisite for satisfactory attainment of supporting competencies and cover knowledge, attitude, and skills. By preparing detailed outlined of competency statements, the learning objectives and outcomes are made clear and unambiguous. Similar approach can to be used in preparing the competency statement for Oral Medicine.
- Clinical domain,
- Communication domain,
- Professionalism domain, and
- Management domain.
[TAG:2]Implications of Implementing CBE  [/TAG:2]
The process of introducing any change will have its implications on the stakeholders, particularly those involved in the education process, including the institution, faculty, students, and committees of instruction, curriculum, and assessment. All these people will need to be involved in the planning and implementation. For teachers, faculty development is required to prepare them to understand and deliver the learning objectives. The assessment committee will have to ensure that assessment methods are introduced that will suitably measure the learning outcome. Performance assessment (e.g., OSCE) and portfolios are recommended. , The competency statements must be made known to the students for them to understand the essence of CBE curriculum without any ambiguity and the assessment criteria. Course handbooks and study guides should highlight the curriculum outcomes relevant to that part of the course. This will help the students understand the expected outcomes and they will be able to gauge their learning. Changes are often met with resistance and when poorly planned without a holistic approach, they can become a failure and hinder future attempts at change. What is most necessary is that the DCI usher in reforms and ensure that all dental schools adopt the reforms and maintain uniformity in curriculum. Using Kotter's eight-step process as a conceptual framework to lead change is an effective method of seeing the change through and can be adapted to introduce change. 
The PCD designed for European dental schools may not be usable as it is in the Indian context. Therefore, we have to address certain key issues that are faced in our country. Our CBE model should address the need for preventive care and motivate people to practice healthy habits and quit deleterious habits such as use of tobacco, and generate awareness of oral health and availability of treatment and ethical practices. Our graduates should also adopt the practice of universal precautions for infection control, as prevalence of iatrogenic infections is higher in the subcontinent. Another important issue is the curriculum content; most of the diseases that have been extensively studied in the west may not be routinely encountered in our country. Therefore, curricular content should address community needs. Although majority of the institutions have vision and mission statements, the outcomes are not congruent to stated objectives. Somewhere in the process of educating students, the vision and mission statements are left in a vanishing trail.
| Conclusion|| |
Development of competency statement for any curriculum requires focused and concerted efforts. Vague competence statements lead to ambiguity and misguided assessment approaches. Such efforts require: Involvement of all stakeholders; time; thorough preparation; in-depth knowledge of curriculum design, methods of instruction, and assessment; and visionary leadership. CBE system may not be the panacea for Indian dental education, but it definitely does address the need for change and uniformity across the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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