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Clinical Competence of Graduates of Community-Based and Traditional Curricula

Key words: community-based education, extramural programs, dental education, clinical competence

Submitted for publication 05/24/05; accepted 09/09/05

	Abstract

Top Abstract Code program description Methods Results Discussion Conclusions References

 
As community-based dental education programs proliferate, so do concerns about the quality of education at extramural sites. While there have been some comparisons of the effects of community-based programs on attitudes and perceptions of competency, there is virtually no information about whether such programs can train students to carry out standard dental procedures as well as if they were prepared in the dental school proper. To address this gap in our knowledge about the educational outcomes of community-based programs, the following performance measures were retrospectively compared for 457 students in traditional senior year curricula and fifty seniors in a community-based program: scores and pass/fail rates on the Northeastern Regional Boards (NERB), clinical production, passage of competencies, and on-time graduation rates. Students in the CODE (Community-Oriented Dental Education) program at the University of Medicine and Dentistry of New Jersey (UMDNJ)-New Jersey Dental School (NJDS) demonstrated significantly higher scores on the restorative section of the NERB, but this did not translate into a better overall pass rate. CODE students passed the same competencies as graduates of the traditional program, yet demonstrated appreciably higher clinical productivity and on-time graduation rates. The additional clinical experiences for the CODE students may be a factor in their higher board scores. Based on these data, it is concluded that community-based dental educational programs can be at least as effective as intramural (school-based) educational experiences in providing students with a sound clinical education.

A primary question that arises when dental schools pursue the laudable goals of increasing access to oral health care in underserved communities and instilling related service values in dental students is: "Can we achieve these goals while still meeting our most fundamental mission, that of educating dentists who are competent in carrying out standard dental procedures?"

Proceeding from the hypothesis that students who participated in the NJDS community-based CODE (Community-Oriented Dental Education) program would develop increased levels of competence in performing dental procedures, a study was undertaken to compare the performance of students educated in traditional and community-based settings of NJDS. Competence was operationally defined as 1) performance (scores) on the Northeastern Regional Board (NERB) licensing exam, 2) clinical productivity, as measured by accumulated clinical points, and 3) on-time graduation rates, which would signify passage of all fourth-year competency tests. Preliminary comparisons of graduates of CODE and graduates of the traditional curriculum with regard to performance on the NERB exam revealed no significant differences when assessed in 1998.¹ Equipped with the results of several more years of licensing exam results from dozens more graduates, NJDS faculty and administrators wanted to reassess the performance of CODE and traditional students and to look at additional measures of clinical competence.

A study of attitudinal results from the CODE program conducted in 2003 revealed that graduates who spent their senior year working in community-based clinics were significantly more supportive of community-based learning and more confident in their clinical preparedness than graduates of the traditional program.² Similarly, a study of dental hygiene students engaged in extramural rotations found an increase in perceived clinical competence, attributed to integration of their skills in the "real world" setting.³ Other research has demonstrated that students in dental programs who were educated in community-based settings displayed a greater understanding of the relevance of social factors when completing a treatment plan.⁴

There is data, therefore, to support the contention that community-based programs can help students learn to practice in a more realistic manner and can assist in developing student confidence in their own clinical abilities. On the other hand, there is very little published data, other than preliminary studies of NERB performance for the CODE program, that evaluate the effectiveness of community learning on dental students’ clinical competence.

	CODE Program Description

Top Abstract Code program description Methods Results Discussion Conclusions References

 
In 1995–96, the NJDS became the only dental school that placed dental students in community-based clinics to complete the entire patient care component of their senior year. In inaugurating this program, an environment was sought that would enable students to perform increased numbers of procedures on a variety of patients in a health care facility that simulated a "real world" private practice. The school already had in place a statewide network of community-based clinics in underserved areas. Initially, two sites proved to be appropriate venues for the CODE program.

Using this network of sites, the CODE program expanded and contracted over time; currently, there are five students out of a class of eighty-six NJDS fourth-year students participating in the program. The current site is an eight-operatory center adjacent to a county nursing home and nutrition center in Northfield, New Jersey, several miles from Atlantic City. The state and county provide partial support for the clinical facility and operation.

There were once three CODE sites with fifteen participants. In 2001, the school’s Advanced Education in General Dentistry (AEGD) program expanded, leaving an insufficient number of operatories to continue CODE at the site that housed both programs. Because the AEGD program gained GME support and had greater income potential, NJDS chose to expand AEGD rather than continue CODE at that site. The other CODE site in Plainfield, New Jersey, was housed in a Federally Qualified Health Center, where management of the dental clinic was shared with the clinic’s administration. It became apparent that the educational goals of CODE were not harmonious with the patient care goals of the center, and NJDS withdrew participation from the center after the first year. These financial and administrative considerations led to a reduction to one CODE site.

In general, the CODE concept involved placing five students at a community-based site for the majority of their senior year supervised by calibrated generalist faculty supplemented with discipline-focused faculty from the dental school and community. Under this model, the faculty role was expanded to include patient care, and students were required to participate in community service. Consequently, the CODE curriculum contained clinical, didactic, and community service components.

The clinical component involved CODE students spending four days per week delivering patient care at the extramural clinic. Each CODE student had his or her own operatory, and the five students shared four dental assistants. While students could perform any general practice procedure on any given day, they could schedule more complicated procedures when discipline-focused faculty were available. In addition to clinical practice at the CODE site, certain discipline-focused rotations, such as hospital rotations, orthodontics, and manikin practice scheduled in Newark, rounded out the clinical experience.

CODE students’ patient care was overseen on site by two full-time faculty, a CODE director, and an assistant director who alternated between supervising student’s clinical work and treating patients. The CODE director served as group practice administrator (GPA), making sure that students made sufficient progress toward graduation requirements. These generalist faculty underwent intensive calibration at the dental school prior to teaching at the CODE site and continue to return to the dental school for calibration refreshers and updates. Their supervision was supplemented by departmental faculty who reside in the community, including a periodontist and an endodontist for one half-day per week as well as by an oral surgeon for one full day per week. Additional, regularly scheduled visits by faculty from Newark not only augmented faculty calibration but also offered students diverse perspectives.

The didactic component included all didactic courses in the traditional fourth-year curriculum. Students spent one day per week at the dental school in Newark for didactic classes and participated in treatment planning seminars with their Newark-based counterparts via video teleconferencing.

Fourth-year students are encouraged to participate in Continuing Dental Education (CDE) courses to broaden their knowledge and be introduced to CDE. Special arrangements with the NJDS Department of CDE permits NJDS students to enroll in up to three NJDS-sponsored courses at no charge, and CODE students were strongly encouraged to take advantage of this opportunity.

Moreover, additional didactic experiences in practice management were afforded through the CODE setting. For instance, periodically a local practitioner delivered a lunchtime presentation on practice management topics. Students were introduced to the business operations of the clinic through access to their production printouts and participation in monthly meetings with site staff, including a patient care coordinator (who arranges appointments), intake person, office manager, and full-time dental assistants. These meetings included staff presentations concerning working with a number of different insurance plans.

The community service component of the program broadened the students’ community learning experience. During academic year 2003–04, CODE students provided comprehensive care to HIV-positive patients in a special care clinic. In conjunction with patient care, students attended lectures about HIV from calibrated faculty. All NJDS fourth-year students are required to engage in sixty credits of selective/elective credits. Accordingly, each CODE student is involved in at least sixty hours of combined community service and continuing education; this constitutes the student’s fourth-year selective/elective program.

Taken as a whole, the CODE experience was structured to be different from the dental school in Newark, yet all competencies, materials, and methods were essentially the same. CODE faculty used the same grade forms and competency evaluation criteria as those used at the dental school. The CODE site participates in the NJDS Continuous Quality Improvement program, completing patient record reviews, final case reviews, and patient satisfaction surveys to ensure standards of care are upheld. All clinical protocols in the NJDS Clinic Manual are observed, but adopted for the CODE site. Notably, in 1998, CODE became the community-based dental education program in the nation subjected to the rigors of a CODA accreditation self-study and site visit and received a commendation. In 2005, NJDS, including CODE, underwent the same process and again received a commendation.

Student participation in CODE is voluntary, and the selection process is conducted by a committee comprised of the associate dean for academic affairs, associate dean for student affairs, and assistant dean for clinical affairs. Group practice administrators who have worked with individual students since their second year provide written input to the Selection Committee regarding their students.

Students who are on academic probation are not eligible to be considered for selection. In addition, because selection is completed in March, students who do not appear likely to complete their third-year competencies by June are prohibited from participating. After meeting these minimal qualifications, selection is performed on a random basis with each qualified student being assigned a random number. Students assigned a number in excess of the available CODE positions are placed on the wait list. If a selected student withdraws after selection is completed, an alternate student is selected from the wait list.

Each year approximately one-half of the third-year students express an interest in participating in CODE. The random basis for selection ensures that students ranked in the lowest and highest quarters of the class have equal chances of being selected. A comparison of the cumulative GPA (for years one through three) of students in the CODE and traditional curricula over the history of the program did not find a significant difference between the two groups. The mean GPA for students who became CODE participants was 3.18, and the mean GPA for students who remained in the traditional program was 3.19. Combined with data that shows CODE and traditional students performed similarly on the written portion of the boards, this data demonstrates the parity of students who are selected to participate in CODE and those who are not selected.

In effect, students representing a wide range of abilities participate in CODE. One year a student who ranked sixty-seven out of a class of sixty-eight was selected, as did students ranking in the top five of the class. It is truly a "luck of the draw" situation once the inclusion criteria are met.

	Methods

Top Abstract Code program description Methods Results Discussion Conclusions References

 
Scores for candidates who gave permission to NERB to release their results to NJDS for the spring of the years 1996–2003 were obtained from existing files within the dean’s office. Scores for students who were retaking the exam or were from another dental school were excluded. Separate independent t-tests were used to compare NERB scores for CODE participants and graduates of the traditional curriculum. Scores for the written exam, the simulated patient clinical (manikin) exercise, and the restorative/periodontics exercises on live patients were compared. In addition, scores were recoded into pass and fail categories, and then chi-square tests of independence were conducted. A priori alpha was set at alpha=0.05.

Whether students were in the CODE or the traditional curriculum, all were required to pass the same number of competency exams to qualify for graduation. Individual clinical competency exams are administered and evaluated by clinical departments. Fourth-year students are required to pass a defined set of fourth-year competency exams in order to graduate. Information was obtained from the registrar concerning who among the past graduating students (1996–2004) did not complete their senior year competencies in time for graduation, and a list was prepared to compare competency attainment by graduates of CODE and the traditional curriculum. Chi-square tests of independence were conducted for this data as well.

Clinical productivity at NJDS is assessed by using a relative value unit based upon the length of time normally required to complete the procedure. Information from the school’s clinical information database was collected to document how many clinical points for the various disciplines and for overall clinical activity were earned by CODE students and their peers in the traditional curriculum. These data were available for graduating classes of 2001 through 2004, and independent t-tests were used to compare the clinical production of CODE students and students in the traditional curriculum. This study was approved under expedited review by the UMDNJ Newark Institutional Review Board, Federal Wide Assurance (FWA) number 00000036 on July 22, 2005.

	Results

Top Abstract Code program description Methods Results Discussion Conclusions References

 
A total of 457 out of 572 (79.90 percent) graduates—all of whom graduated from NJDS between 1996 and 2003—took the NERB, released their scores to NJDS, and were thereby included in the study. Of the CODE students, fifty out of sixty-three (79.37 percent) took the NERB and released their scores; for the traditional students, the participation rate was 79.96 percent (Table 1).

	Discussion

Top Abstract Code program description Methods Results Discussion Conclusions References

 
Differences were neither expected nor found between CODE and traditional students on the written portion of the board exams. Nonetheless, the comparison was performed to demonstrate equality among the groups with regard to academic ability evidenced by the written exam.

One explanation for higher scores on the restorative portion of the exam is that CODE students develop a somewhat higher level of competence by completing more of the tested procedures. In light of the large differences between the mean clinical production points between the two groups, it seems possible that more practice in restorative procedures, as demonstrated in Table 4, enabled CODE students to achieve higher scores.

Alternatively, it is possible that the difference in performance on the restorative exam could be explained by salient differences in the learning experience. Which particular aspects of the program influence the clinical learning outcome under study gives rise to a larger set of questions that deserve further exploration. Are the differences in performance due to a lower student-faculty ratio at the extramural sites or to working with the same faculty over the year? Are the improvements in clinical production due in part to differences in patient or dental assistant availability, waiting time for faculty, or no show rates? These are all possible aspects of the CODE learning experience that could impact its various outcomes.

The fact that the CODE students produce more clinically is not surprising, given the program’s structure and expanded clinic hours. The data concerning on-time graduation rates, again, is as expected, given that differences in the setting and hours are likely to allow CODE students to complete more procedures and competencies.

In a past study,¹ students in the CODE curriculum were matched with students in the traditional curriculum based on cumulative grade point average at time of selection and the number of comprehensive care points students had completed at time of selection. No significant differences were found between the two groups in terms of pass/fail rates. Thus, this new and larger study (without matching) essentially confirms the earlier study’s suggestion that there is no difference in the NERB passing rates of CODE and traditional students. It is possible that the pass rate for both groups is so high as to create a ceiling effect, thus making it difficult to note variability between the two groups.

The NERB licensing exam provides a fairly well-accepted measure of competence and hence an appropriate starting point for examining the impact of community-based dental education experiences on student learning. However, misgivings have been expressed concerning the accuracy and validity of "one-shot" exams and variability problems in exams using real patients (see, for instance, Gadbury-Amyot et al.,⁵ Formicola et al.,⁶ Ranney et al.⁷). Yet, these are the only existing practical examinations administered by an independent third party in a relatively standardized format that are currently in widespread use in the region. Interpretation of results should take into account that accuracy of the NERB exam as a measure of clinical competence is equivocal.

Data for licensing exams were available only for those students who released their scores to NJDS. It is possible that students who released scores differed in some way from those who did not. Since the proportion of CODE and traditional students releasing their scores was approximately equal overall (79.37 vs. 79.96, respectively), it is believed this will have little effect on the study’s findings. However, when interpreting results, one needs to consider that scores for approximately 20 percent of the students in each group were not included.

As NJDS experienced the value of the CODE model, aspects of CODE were adopted into the traditional clinic environment. For example, when the school had the opportunity to build a new pavilion, the clinics were structured with an integrated front desk area to more closely approximate a private practice. In addition, the department of restorative dentistry was created by combining operative and fixed and removable prosthodontic faculty, in an attempt to have more cross-functioning of faculty, thereby emulating CODE’s integrated environment.

Moreover, the curriculum 2010 committee that is charged with developing a new curriculum for the school has, as part of its objectives, to develop ways to bring the benefits of CODE to the in-house curriculum.

The focus of this study was the impact of the program on students’ clinical competence. However, the program certainly has effects on the school itself, such as finances, effects on patients and the community, such as access to service, and on other aspects of students, such as attitudes toward community service. These issues are of critical importance in assessing community-based education models on a more comprehensive level. Collectively, outcomes related to students, school, and community need to be considered. While these data on clinical competence outcomes are encouraging, they are but one step in establishing whether extramural dental education programs should be sustained. Once the benefits, or, at minimum, the parity of community-based dental education programs as compared to traditional programs, are firmly established at all three of these levels (patients, community, and students), the financial sustainability of such programs may become a concern.

	Conclusions

Top Abstract Code program description Methods Results Discussion Conclusions References

 
If the goal is to educate dentists to the highest level of competence, the outcome of significantly higher scores in restorative exercises among graduates of the community-based curriculum is of interest. Still, the fact that there is no difference in pass/fail rates is of critical importance and may be considered the bottom line for comparing the two methods of education in regard to clinical competence.

For quite some time after publication of the influential 1995 Institute of Medicine report, Dental Education at the Crossroads: Challenges and Change,⁸ recommendations for major changes to make dental school curriculums more community-oriented continue. In 2002 an international collaboration of dental educators called for changes in dental education to include an emphasis on social responsibility and dental public health.⁹ A 2003 report from the U.S. National Academy of Science recommended that all programs and institutions engaged in the clinical education of health professionals develop competencies to provide patient-centered care including a focus on public health.¹⁰ These reports are bolstered by documented compelling needs to provide oral health care to the underserved.¹¹ In short, because of the catalytic effect of the Robert Wood Johnson project and recommendations from influential groups, continued growth in community-based dental education programs can be expected.

While most educators would agree it is essential that community-based dental education programs maintain established standards and that "the basics" are not lost in pursuit of additional, albeit valuable, ideals, some faculty remain skeptical. But as the results of this comparison of performance on licensing exams demonstrate, community-based dental educational programs can be at least as effective as intramural educational experiences in providing students with a sound clinical education.

Financial and administrative considerations in operating extramural educational programs are many, and beyond the scope of this study, although they impacted the number of students participating. Additional data on these topics should be collected and disseminated in order to provide the full spectrum of information about such programs to schools that are considering or attempting implementation.

	Acknowledgments

The authors wish to acknowledge Dr. Pamela B. Matheson who assisted in the program evaluation and manuscript review, and thank Ms. Regina Dreyer Thomas for her able editorial assistance and persistent support. We are indebted to Ms. JoAnne Lametta, the school’s registrar, for answering our many requests for information quickly and with a smile.

We are continually grateful to Drs. Richard Buchanan, Robert Saporito, William Cinotti, and Paul Desjardins for their vision in founding the CODE program; to Drs. Cosmo DeSteno and George Mardirossian, who shepherded the program in its earlier years; to Drs. Jill York and Andrew Youngblood who have picked up the torch; and to the many generous faculty from NJDS who have contributed their thoughts to the development of CODE, calibrated the faculty, and ensured that NJDS standards were upheld. We also deeply appreciate the commitment to excellence of our CODE faculty, including those from the community and school, and our students who invigorate the CODE program each day and make CODE the dynamic conduit that it is.

	Footnotes

 
Ms. DeCastro is an Instructor, Department of Community Health and currently Director of Student Advisement and Support Programs; Dr. Bolger is an Assistant Professor, Department of Community Health and Director of the Northfield CODE site and program; and Dr. Feldman is Dean and Professor, Department of Community Health and Department of Restorative Dentistry—all at the University of Medicine and Dentistry of New Jersey-New Jersey Dental School. Direct correspondence and requests for reprints to Ms. Jeanette DeCastro, Office of Student Affairs, UMDNJ-New Jersey Dental School, Room B846, P.O. Box 1709, Newark, NJ 07101-1709; 973-972-7816 phone; 973-972-0309 fax; decastje{at}umdnj.edu.

	REFERENCES

Top Abstract Code program description Methods Results Discussion Conclusions References

 

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8. Field MJ, ed. Dental education at the crossroads: challenges and change. A report of the Institute of Medicine. Washington, DC: National Academy Press, 1995.
9. Zarkowski P, Gyenes M, Last K, Leous P, Clarkson J, McLoughlin J, et al. The demography of oral diseases, future challenges and the implications for dental education. Eur J Dent Educ 2002;6(Suppl 3):162–6.[Medline]
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