In this article, the Task Force on Student Outcomes Assessment of the American Dental Education Association's Commission on Change and Innovation in Dental Education describes the current status of student outcomes assessment in U.S. dental education. This review is divided into six sections. The first summarizes the literature on assessment of dental students' performance. Section two discusses catalysts, with a focus on problem-based learning, for development of new assessment methods, while the third section presents several resources and guides that can be used to inform selection of assessment techniques for various domains of competence. The fourth section describes the methodology and results of a 2008 survey of current assessment practices in U.S. dental schools. In the fifth section, findings from this survey are discussed within the context of competency-based education, the educational model for the predoctoral curriculum endorsed by the American Dental Education Association and prescribed by the Commission on Dental Accreditation. The article concludes with a summary of assessments recommended as optimal strategies to measure three components of professional competence based on the triangulation model. The survey of assessment practices in predoctoral education was completed by 931 course directors, representing 45 percent of course directors nationwide, from fifty-three of the fifty-six U.S. dental schools. Survey findings indicate that five traditional mainstays of student performance evaluation-multiple-choice testing, lab practicals, daily grades, clinical competency exams, and procedural requirements-still comprise the primary assessment tools in dental education. The survey revealed that a group of newer assessment techniques, although frequently identified as best practices in the literature and commonly used in other areas of health professions education, are rarely employed in predoctoral dental education.

Assessing dental students' competence: best practice recommendations in the performance assessment literature and investigation of current practices in predoctoral dental education.

This 2009 study of dental school curricula follows a similar one conducted in 2002-03. Through a web-based survey, the authors gathered information from dental schools about 1) past trends in curricular change over seven years; 2) current changes under way in dental school curricula; 3) significant challenges to curricular innovation; and 4) projected future trends in curricular change and innovation. Fifty-five schools (fifty U.S. and five Canadian) responded to the survey for a response rate of 86 percent. In addition to background information, the survey requested information in four broad areas: curriculum format, curriculum assessment, curriculum innovation, and resources needed for curriculum enhancement. Forty-nine percent of the respondents defined their curriculum format as primarily organized by disciplines. Half of the respondents reported the use of problem-based and case-reinforced learning for a section or specific component of some courses. In a significant change from the 2002-03 study, a high proportion (91 percent) of the responding schools require community-based patient care by all students, with just over half requiring five or more weeks of such experience. Competency-based education to prepare an entry-level general dentist seems well established as the norm in responding dental schools. Forty-three percent or less of the responding schools indicated that their students participate with other health professions education programs for various portions of their educational experience. Since the 2002-03 survey, dental schools have been active in conducting comprehensive curriculum reviews; 65 percent indicated that their most recent comprehensive curriculum review is currently under way or was conducted within the past two years. Respondents indicated that the primary reasons for the configuration of the current curriculum were "perceived success" (it works), "compatibility with faculty preferences," "faculty comfort," and "capacity/feasibility." Key catalysts for curricular change were "findings of a curriculum review we conducted ourselves," students' feedback about curriculum, and administration and faculty dissatisfaction. There was an increase in the percentage of schools with interdisciplinary courses, especially in the basic sciences since 2002-03, but no change in the use of problem-based and case-reinforced learning in dental curricula. Respondents reported that priorities for future curriculum modification included creating interdisciplinary curricula that are organized around themes, blending the basic and clinical sciences, provision of some elements of core curricula in an online format, developing new techniques for assessing competency, and increasing collaborations with other health professions schools. Respondents identified training for new faculty members in teaching skills, curriculum design, and assessment methods as the most critical need to support future innovation.

Curriculum change in dental education, 2003-09.

Those who educate medical students and physicians work in a world suffused with the concept of competency. This article examines the intellectual origins and hidden assumptions of this concept and argues that it is an inadequate, and even harmful, concept to use as a guiding motif for professional education. The competency model-which tends to be top-down and prescriptive-does not provide the framework for objective educational assessment that it claims to provide. The alternative apprenticeship model is more appropriate for professional education and is more consistent with what psychological research has shown about the acquisition of expertise.

Medical education and the tyranny of competency.

Competency-based education (CBE) is a model that guides the educational process toward acquisition of the knowledge, skills, and attitudes needed for effective professional practice in service of the public. Increasingly adopted by medicine and other professions, the CBE model involves establishing competency goals, developing curricula and other experiences designed to help students reach these goals, integrating instruction in the full range of competencies throughout the educational sequence, guiding and evaluating student learning through ongoing assessment of competence, and revising courses and activities in light of student competence outcomes. Included in a full CBE model are attention to unintended learning outcomes (the “hidden curriculum”) and to areas not covered (the “null curriculum”), and efforts to promote education based on individual student learning trajectories as opposed to set courses or number of hours. Within professional psychology, we suggest that APA accreditation is aligned with a version of the CBE model; and significant progress has been made in identifying and measuring professional competencies. However, these are merely tools that can help training programs implement a broader CBE educational model that we contend has not been widely realized in professional psychology. This article reviews CBE and its application in medicine, discusses the benefits and criticisms of CBE, and considers what a fuller realization of CBE would look like in professional psychology training programs, including graduate programs, practicum, internships, and postdoctoral settings.

Competency-Based Education for Professional Psychology: Moving From Concept to Practice

It is generally accepted that repetition of procedures is necessary to develop clinical skill in dentistry. Although there is a rich empirical research tradition in medicine establishing competency levels for new procedures, investigations of the shape of learning curves for clinical techniques are rare in dental education. Data were reviewed from three classes (n=465) of students at the University of the Pacific Arthur A. Dugoni School of Dentistry in seventeen clinical skills in five departments for which test case (independent performance) data were available. It was hypothesized that a learning curve would be observed with gradually rising scores as a function of amount of repeated test case work and general practice experience. Other factors, such as faculty ratings and clinical GPA, could be expected to modify this curve. No evidence was found that test case performance was affected by number of previous test cases, number of practice (ungraded) procedures previously completed, faculty ratings of technical skill in the discipline by quarter, faculty ratings of patient management and of clinical judgment competencies, overall clinical GPA, and performance on initial licensure examinations. The absence of a pattern showing that amount of prior experience improves clinical performance raises questions about the practice of setting "requirements" for graduation and challenges dental educators to better explain the presumed relationship between practice and performance and the validity of clinical evaluation of performance based exclusively on the objective technical quality of work samples. The literature on learning curves and on competency-based education offer alternative insights into what students are actually learning but schools are failing to measure in the clinical experience.

Learning Curves: What Do Dental Students Learn from Repeated Practice of Clinical Procedures?

Competency-based dental education was introduced in 1993 and has proven to be a robust innovation, guiding curricular design, clinical education and evaluation, and accreditation. At the same time, it has been irregularly implemented and is understood in different ways. These paradoxes were explored in a survey of academic and clinical deans and chairs of departments of endodontics and restorative dentistry at U.S. and Canadian dental schools. It was confirmed that fewer than half of the respondents can identify the ADEA and ADA definition of competency. Significant differences were reported in the perceived understanding and value placed on competencies and their impact on dental education. Differences were also found to exist in evaluation practices and in how evaluation data are used to determine students' readiness for graduation. It is concluded that the openness of the competency concept is one reason for its longevity and usefulness in dental education.

Frank W. Licari

Papers

Some Paradoxes in Competency-Based Dental Education